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CHAPTER ONE

ASSESSMENT OF PATIENT/FAMILY

1.0 Introduction

Assessment can be defined as critical analysis and evaluation or judgments of the status or

quality of a particular condition, situation or other subject of appraisal, (Weller, 2009).

Assessment is the first phase of the nursing process. It includes collection of data from the

patient/family about their health status, hence enabling the nurse to render quality health care

to the patient through interviews, medical records, laboratory investigations and

examinations. It covers the patient’s particulars, family medical/surgical history, family

social/economic history, patient’s developmental history, patient’s concept of illness,

patient’s lifestyle and hobbies and patient’s past and present medical/surgical history. This

begins from the day of admission and ends after termination of care.

1.1 Patient’s Particulars

According to Weller (2009), particulars of a patient are the facts or details about them which

are written down and kept as records.

Mrs. E.A., a 33year old woman and the fourth born among eleven siblings, born to Mr. K.A

and Mrs. A.B on the 06/05/1985. She is a Bono by tribe, hails from Tom, a town in Nkoranza

and currently lives at Nkoranza in a house with number NDA 304, in the Brong Ahafo.

According to the patient, she had her education up to junior high school and could not

continue due to financial constraint of her parents. Mrs. E.A is married to Mr. A.M.K. with

whom she has one child who is 6 year old boy. Mrs. E.A speaks Bono and little of English.

Mrs. E.A is a hair dresser by occupation.

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Mrs. E.A. is 1.5m tall, dark in complexion and weighs 60kg. Mrs. E.A has no tribal mark on

her face and has no physical disability. Her next of kin is S.A who is her sister.

1.2 Patient’s / Family’s Medical History

Patient is a known hypertensive and has being admitted before for treatment of hypertension.

According to Mrs. E.A, hypertension runs through her family. She affirmed that her

grandmother suffered from hypertension before she died of stroke and her mother is also a

hypertensive patient. Aside the hypertension that runs through her maternal side of her

family, there are no known hereditary diseases such as asthma, diabetes mellitus, sickle cell

disease and mental illness in the family. She also said that, there are no chronic and infectious

conditions like cancer, tuberculosis, epilepsy and leprosy in the family. Aside her

grandmother who is dead, all her relatives are alive, except one of her mother’s sister who

died of snake bite when she went to the farm.

Furthermore, patient stated that they sometimes suffer from minor symptoms such as

headache, fever, diarrhoea and cough which they usually treat at home using over the counter

medications such as paracetamol, and other anti – malaria drugs. They sometimes used herbal

medications bought from local market or acquired from the farm. She stressed that when

home management fails, they report to the hospital for further treatment. They normally

receive treatment at the St. Theresah’s Hospital in Nkoranza, in Brong Ahafo Region.

According to Mrs. E.A, she has been hospitalized with hypertension before. Patient

verbalized that she is has no known allergy.

1.3 Patient’s/Family Socio-Economic History

Mrs. E.A is hair dresser by profession. She has her own hair dressing shop in Nkoranza and

has apprentices who are learning from her. She works from Monday to Friday and

occasionally on Saturdays if someone request her services. According to Mrs. E.A, she

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averagely has at least four to five customers daily. Mrs. E.A said the income from her work is

used to support that of her husband Mr. A.M.K, who is the main bread winner of the house.

Mr. A.M.K is a taxi driver. According to Mrs. E.A, she and the husband also has cashew farm

at Sampa. In difficult times, they are supported by her family financially but she said their

income is normally sufficient for the upkeep of her family and as such they don’t normally

require financial assistance. She said as the fifth born of her parents, she normally sends

money to her parents and also takes care of her younger siblings. According to Mrs. E.A, she

and the husband are middle class, since she and the husband are both working and they also

have a cashew farm that gives them money each year. Patient and her family are registered

with the national health insurance scheme.

Mrs. E.A is Christian and worship at the Methodist Church of Ghana in Nkoranza. She is a

member of the church choir. According to patient, she is also an active member of the women

fellowship in the church. Her church celebrates festivals such as Easter and Christmas.

Even though patient could not throw much light on taboo and other cultural practices, she

said in Sampa where they have the cashew farm, there are days that are regarded at a taboo to

go to farm. She also said she was raised her parents to respect all adults and to be

hardworking as well.

1.4 Patient’s Developmental History

According to Weller (2009), development is the process of growth and differentiation.

Also Weller (2009), describes growth as the progressive development of a living thing

especially the process by which the body reaches its point of complete physical development.

Moreover Weller (2009), defines maturation as ripening or developing.

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According to patient, her mother experienced normal pregnancy for a period of nine months

and did not experience any disease during that period. She did not attend antenatal.

According to Mrs. E.A, said she was told by her mother that she was delivered per

spontaneous vaginal delivery by traditional birth attendant at home. Her mother had no

problem during the childbirth or peurperium. She said her mother started going for post natal

care in order to immunize her. She was immunized against the six childhood killer diseases

which is evidenced by a mark of her deltoid muscle and also indicated in her weighing card.

According to Mrs. E.A, growing up she did not suffer from any serious diseases that could

have impeded her development. According to Mrs. E.A., she was told by the mother that at

about seven months she was sitting, crawling at nine months and could walk at after one year.

She said her mother told her that she started didn’t do exclusive breast feeding as she started

feeding her food such as porridge at 3months and could eat all meals prepared at home and as

a result was from breast milk after one and half years. She also added that, she started her

primary education at the age of 7 at a Methodist school at Tom. She continued her education

till she completed junior high school. She could not continue her education because her

parents could not finance her education because of financial distress.

Weller (2009) defines puberty as the period during which adolescents reach sexual maturity

and become capable of reproduction. Even though Mrs. E.A. developed her secondary sexual

characteristics such as development of breast, growing of hair in the armpit and around the

pubic-areas as early as twelve years, she experienced her menarche at age eighteen. Since she

has regular menstrual cycle of 28 days and menstrual flow of 5 days. According to Mrs. E.A,

she never had a sexual relationship till she married her husband. According to Mrs. E.A, she

had an aspiration to be a banker by profession when she grew up but because she was not

able to continue he education, she then switched to hair making. She has no regret over her

choice of profession now.

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According to Erikson’s theory of psychosocial development (1959), there are eight distinct

stages with each possible results, thus either success or failure personality. These theory;

1. Trust versus mistrust (birth to 1 years)

2. Autonomy versus shame and doubt (2 to 3 years)

3. Initiative versus guilt (3 to 5 years)

4. Industry versus inferiority (6 to 11 years)

5. Identity versus role confusion (12 to 18 years)

6. Intimacy versus isolation (19 to 40 years)

7. Generativity versus stagnation (40 to 65 years)

8. Integrity versus despair (65 to death)

Mrs. E.A is within the sixth stage (intimacy versus isolation). This stage takes place during

the adulthood of people. During this stage, the major conflict centers on forming intimate,

loving relationships with other people. The individual learns to share and care without

loosing themselves. Isolation on the other hand occurs when the person fails to find a partner.

They feel alone and isolated. Mrs. E.A is married happily and has one child. She is also

looking forward to giving birth again in the near future.

1.5 Patient’s Obstetric History

According to Mrs. E.A., she experienced her menarche at age eighteen and had a regular

menstrual flow of 5 days and a normal 28 days cycle. She does not have history of menstrual

pains. Patient has had only one pregnancy and delivered per vagina spontaneously without

any complications. Currently, she has only one child, who is alive. Mrs. Y.A has practices

natural family planning method and the use of condom. She has no history of contraceptive

use.

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1.6 Patient’s lifestyles / hobbies

Mrs. E.A often wakes up early in the morning around 5:00am. She says a prayer performs her

first oral hygiene, empty’s her bowel and her bladder. She then sweep her compound and

prepares breakfast for her family. After that she takes her first bath, eats her breakfast and

bath her child and make him ready for school. She normally leaves for work, which is about

20 minute walk from her house after the school bus of her child has picked him to school.

She mostly cooks at her shop in the afternoon. She normally arrive at work at work between

8:00 and to 8:30am. She normally returns from work to home around 5pm in order to prepare

supper for her family.

Mrs. E.A empties her bowels twice daily and performs oral hygiene twice as well, thus

morning and evening and she eats three times daily and sleeps at 10:00pm after watching her

favourite telenovela programs such as “kung rang” or “maahubali” on adom television or

angel television respectively. On Wednesdays, she normally attends church choir practices.

The above mentioned routines are done from Monday to Friday. Nevertheless, when Mrs.

E.A feels tired at work or on days that customers do not seek her services, she spreads a mat

down at her store and rest.

During the weekends, Mrs. E.A said she wakes up at 6: 00am on Saturdays, she visits the

toilet, brush her teeth and performs her household chores, takes her breakfast and bath her

child. She normally wash their dirty clothing on Saturdays. She normally rest in the morning

or sometimes joins her church women group activities such as sports, cleaning exercises or

choir practices. In the afternoon, she mostly attends wedding ceremonies and funerals.

She also said on Sundays she wakes up at 6:30am prepares and leaves for church at 8:00am.

She closes at 12:00pm. She returns home for lunch and visit the houses of her friends who

stay nearby. She said because her husband does not normally go to work on Sundays, they

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make time for themselves, visit friends and family. She has no difficulties in grooming,

dressing and walking.

She further stated that, she mostly has good appetite when she is not ill. Her favorite meals

are fufu with light soup and jollof rice with fried chicken. Mrs. E.A. said she takes alcohol

occasionally, but since she was diagnosed of hypertension, she has stopped drinking it. She

added that she does not smoke. She likes to watch television programs especially telenovela

and chats with her friends during her leisure periods.

Mrs. E.A is an extrovert, kind, caring but sometimes when provoked by neighbors, she fights

them back. She also loves to express her emotions through talking she has good

communication skills as well. She also communicate with her son using nonverbal

communication such as gestures whenever he is doing something wrong.

After the interaction with my patient, I realized that, Mrs. E.A is a good woman, with a caring

heart and above all, she is friendly. She has no drug allergies.

1.7 Patient’s Past Medical History

Mrs. E.A never suffered any child hood disease such as measles, polio myelitis or whooping

cough but has suffered from chicken pox before. According to Mrs. E.A, she has been

hospitalized with the diagnosis of hypertension on three different occasions. She was first

diagnosed of hypertension at the age 25 years and has since being on antihypertensive.

Patient said she was supposed to go for week B.P check every week but due to her busy

schedule, she normally doesn’t go for the blood pressure checking unless she feels headache

or palpitation. Her previous medical history includes drugs such as Tab Nifedipine, Tab

Bendroflumethiazide and Lisinopril before.

Also, she has been treated on OPD bases on tonsillitis, bronchitis and nail prick when she

accidentally stepped on one. Occasionally, she experiences minor ailments such as fever or

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cold which she treats using drugs bought from a pharmaceutical shop. But when symptoms

persist or become worse, she seeks medical care at the St. Theresah’s’ Hospital. Patient has

never had any surgery in her life. She does not suffer from any disability due to complication

of any illness. She has no known allergy to any food, drug or animal or insect.

Patient said all she knows about hypertension is the increase in blood pressure and nothing

more. She also verbalized that, she hardly ever visit the hospital for checkups and mostly

refuses to take her medication because she is mostly busy and has the perception that the

hypertension is gone because she does not normally feel sick. She has easy access to health

care.

1.8 Patient’s Present Medical History

According to Mrs. E.A she was feeling well until about three days ago (25/09/2018), when

she started feeling headache and palpitation. She took paracetamol to curb the headache but it

still persisted. According to patient she then took her antihypertensive which was with her in

her house. She said the palpitation subsided till on the morning of 28/09/2018, around 9am,

when she felt dizzy and headache with palpitations. She then left her shop in the care of her

apprentices and went home for her health insurance and came to the out patient department of

the St. Theresa’s Hospital. Her vital signs at the OPD was

Temperature 36.9

Pulse 89bpm

Respiration 20cpm

Blood pressure 190/100mmHg

Patient was then admitted to the females’ ward of the St. Theresah’s Hospital

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1.8 Admission of Patient.

Mrs. E.A was admitted to the females’ ward of the St. Theresah’s’ Hospital per ambulatory

on the 28/09/2018 at 10:30am from the outpatient department accompanied by an OPD nurse.

They were warmly welcome and seat was offered. Patient’s folder was collected from the

OPD nurse and her name was mentioned to ascertain and confirm the identity of the patient.

Mrs. E.A was immediately made comfortable in an already prepared admission bed in

female’s ward with bed number FW-2 because complained of dizziness. I introduced myself

and the staff around to the patient. Mrs. E.A’s particulars were documented into the

admission and discharge book and daily ward state. Upon assessment patient looked ill. She

complained of dizziness, headache and palpitations. Patient was confirmed to be anxious

also.

Her vital signs was checked and recorded as follows

Temperature - 36.9oc

Pulse - 84bpm

Respiration - 21cbm

Blood Pressure - 190/110mmHg

SPO2 - 97%

Laboratory investigations requested on admission were

Blood for Full blood count

Blood for malaria parasite

Blood for blood urea and creatinine

Urine for urinalysis

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Blood sample was taken, sample bottle labelled and sent to the laboratory for the

investigations to be carried out.

On admission patient was managed on the following medications;

Intravenous Hydralazine 10mg stat

Tablet Losartan 100mg daily for 30 days

Tablet Methyldopa 1g bd for 30 days

Tablet Bendroflumethiazide 5mg daily x 30

Tablet Amlodipine 10mg daily for 30 days

Drugs were immediately procured from the pharmacy department. An intravenous cannula

was established and due medication was administered as prescribed. Other medical orders

such as hourly blood pressure monitoring, complete bed rest and education of patient on

condition were all carried out. A care plan was drawn to help solve patient’s identified

health problems from admission till discharge.

Patient was then orientated to ward and its environs such as the toilet, bath room and the

nurses station. They were also introduced to the other patients on the ward. Since the ward

didn’t not have a dining hall, patient was encouraged to eat by the bed side. She was also

told of the visiting hours of the hospital. Patient was encouraged to call home for them to

bring patient’s personal items that she may need at the ward such as towel, sponge, tooth

brush, toothpaste and bucket from the house. She was asked to talk to any of the nurses

around if she needed anything or help.

After these interventions, I told the ward in-charge of my intention of using the patient and

the family for a case study and I was given the permission. I introduced myself to the patient

again that, I am a student nurse of Nurses’ Training College, Sampa, who was conducting a

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care study at the hospital. I then made it known to Mrs. E.A of my desire to give her a

special nursing care for her speedy recovery. She was told that, as part of my training, final

year students are to take a patient each, nurse him or her from the time of admission till time

of discharge and home visits. Mrs. E.A accepted and promised her cooperation and readiness

to give me any information needed for my study. She was told that, she would be discharged

home once her condition was stable and that she were not going to be on the ward forever.

She was also informed that, as part of my care, I would visit their home whiles she was on

admission and after she has been discharged. I promised to keep the data that give out with

utmost confidentiality.

I choose to write my care study on hypertension because even it’s very common in most

people, there are a lot of misconception about it and because it may be asymptomatic, people

who are diagnosed with hypertension default with treatment and come to the hospital only

after complications. I wanted to know more about this condition and to holistically nurse a

patient who was suffering from this ailment.

1.10 Patient Concept of Her Condition

Mrs. E.A said even though she was told of having hypertension some years back and was on

medications, she had been well and felt no pain and going about her day to day activities until

on the 25/09/2018, when she experienced unusual signs and symptoms. She however did not

attribute the present condition to any spiritual forces. She believed that it is just a disease and

had the belief that she would be cured to continue her normal daily activities. She was of the

hope that with good management she would recover soon.

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1.11 Literature Review on Hypertension

Anatomy And Physiology Of The Heart

According to Areti (2012), a literature review is an essential tool for a study and it helps to

identify relevant information about the disease condition. It involves types, causes,

pathophysiology, and treatments among others of hypertension.

Review Anatomy And Physiology Of The Heart

According to Waugh and grant (2010), humans and other vertebrates have a closed circulatory

system: This means that circulating blood is pumped through a system of vessels, this system

consists of the heart (pump), series of blood vessels and the blood that flows through them.

Diagram of the heart

Scalon and Sanders (2010)

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The Heart

It is located near the center of your chest and a hollow structure, Composed almost entirely of

muscle and is about the size of your clenched fist. Enclosed in a protective sac called the

pericardium. In the walls of the heart, two layers of tissue form a sandwich around a thick layer

of muscle called the myocardium. Contractions of the myocardium pump blood through the

circulatory system. The right and left sides of the heart are separated by a septum, or wall. On

each side of the septum are two chambers. The upper chamber (receives blood) is the atrium.

The lower chamber (pumps blood out of heart) is the ventricle. The septum prevents the mixing

of oxygen rich and oxygen poor blood. The heart contracts about 72 times per minute and

Pumps about 70mL of blood with each contraction. Heart muscles are composed of individual

fibers, each atrium and ventricle contracts as a unit. Each contraction begins with a group of

cardiac muscle cells in the right atrium known as the sinoatrial node (SA node). Because the

SA node paces the heart it is known as the pacemaker. The impulse spreads from the pacemaker

to the rest of the atria. From the atria, a signal is sent to the atrioventricular node and then to a

bundle of fibers in the ventricle. When the ventricle contracts, blood flows out.

Cardiac output

The cardiac output is the amount of blood ejected from each ventricle every minute. The

amount expelled by each contraction of each ventricle is the stroke volume. Cardiac output is

expressed in liters per minute (L/min) and is calculated by multiplying the stroke volume by

the heart rate (measured in beats per minute):

Cardiac output = Stroke volume ×Heart rate.

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Stroke volume

The stroke volume is determined by the volume of blood in the ventricles immediately before

they contract, i.e. the ventricular end-diastolic volume (VEDV), sometimes called Preload. In

turn, preload depends on the amount of blood returning to the heart through the superior and

inferior venacave (the venous return). Increased preload leads to stronger myocardial

contraction, and more blood is expelled. In turn the stroke volume and cardiac output rise. In

this way, the heart, within physiological limits, always pumps out all the blood that it receives,

allowing it to adjust cardiac output to match body needs. This capacity to increase the stroke

volume with increasing preload is finite, and when the limit is reached, i.e. venous return to the

heart exceeds cardiac output (i.e. more blood is arriving in the atria than the ventricles can

pump out), cardiac output decreases and the heart begins to fail . Other factors that increase the

force and rate of myocardial contraction include increased sympathetic nerve activity and

circulating hormones, e.g. adrenaline (epinephrine), noradrenaline (norepinephrine) and

thyroxin.

Circulation of Blood

Deoxygenated blood passes from the right atrium into the right ventricle and then goes to the

lungs. From the lungs, blood moves back toward the heart into the left atrium to the left

ventricle and then passes into the aorta to go to the rest of the body

Blood Vessels

As blood moves through the circulatory system it moves through 3 types of blood vessels:

Arteries

Capillaries

Veins

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Arteries: Large vessels that Carry blood from heart to tissues of body e.g., aorta, carotid artery

oxygen rich blood, with the exception of pulmonary arteries. It has thick walls-needed to

withstand pressure produced when heart pushes blood into them.

Capillaries: Smallest blood vessels .Walls are only one cell thick and very narrow. Important

for bringing nutrients and oxygen to tissues and absorbing CO 2 and other waste products.

Veins: Once blood has passed through the capillary systems it must be returned to the heart.

This is done by veins which walls contains connective tissue and smooth muscle. Largest veins

contain one way valves that keep blood flowing toward heart E.g. SVC, IVC, Jugular veins

.Many found near skeletal muscles. When muscles contract, blood is forced through veins.

Blood Pressure

The pressure of the arterial blood is regulated by the blood volume, total peripheral resistance,

and the cardiac rate. These variables are regulated by a variety of negative feedback control

mechanisms to maintain homeostasis. Arterial pressure rises and falls as the heart goes through

systole and diastole. The force of blood on the wall of the arteries is known as blood pressure.

Blood pressure decreases as the heart relaxes, but the rest of the circulatory system is still under

pressure.

Definition of hypertension

According to Hinkle and Cheever (2010), hypertension is defined as a chronic medical

condition characterized by a sustained elevation of blood pressure over a period of time. A

person can be described as hypertensive if there is a constant systolic blood pressure above

140mmHg and a diastolic pressure above 90mmHg. Hypertension is described as a systolic

pressure greater than 140mmHg and a diastolic blood pressure greater than 90mmHg based on

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average of two or more blood pressure readings taken during two or more contacts with the

health care provider.

Hypertension means the heart is working harder than normal, putting both the heart and blood

vessels under strain.

Blood pressure is the pressure exerted by the blood against the walls of the blood vessel

especially the arteries.

It varies with the strength of the heartbeat, the elasticity of the arterial walls, the volume and

viscosity of the blood and the individual’s health, age and physical condition.

In the elderly, it is defined as the persistent elevation of blood pressure above160mmHg and

diastolic blood pressure above 90mmHg. It is usually called the silent killer because it is

asymptomatic and a major public health concern. Two factors determine blood pressure:

 Change in cardiac output

 Change in Peripheral resistance or both.

Regulation Of Blood Pressure

 Baroreceptor reflex ; causes changes in arterial pressure

 Renin-Angiotensin Aldosterone system (RAAS) ; causes Long term adjustment of arterial

pressure

 Kidney compensation ; causes endogenous vasoconstriction

 Aldosterone release

Incidence

Between 20% and 25% of the adult population in the United States has hypertension (Hinkle

and Cheever, 2010). According to Hinkle and Cheever (2010), hypertension is more severe

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and prevalent in blacks than in whites by a ratio of 2:1 approximately, 14% of the worlds’

populations have hypertension.

According to Hinkle and Cheever (2010), In Africa, prevalence of hypertension is higher in

urban areas than in rural areas, it tends to affect women over 55years of age. It is also common

in the second trimester of pregnancy. Recent studies have revealed that condition is increasing

among teenagers. In Ghana, a study by Professor Albert Amoah shows that, 1 out of 4

Ghanaians aged more than 35years have hypertension (Report on Hospital Community survey,

Accra and Ashanti Regions)

In Ghana the incidence on hypertension was rated at 4.28 percent per 1000 reported cases of

diseases in the She was under constant observation and two hourly B.P monitoring.

Preparation of patient and family for discharge commenced on the first day of admission as it

was communicated to them that, the hospital was just a temporary place to keep patient and

to help them recover.

Table one below Hinkle and Cheever, (2010), classifies blood Pressure as

Table one: Classification of blood pressure

Category Systolic (Mm\Hg) Diastolic (Mm\Hg)


Desired 120 80
Normal < 130 < 85

High Normal 130 – 139 85 – 89


Hypertension
Stage 1 mild 140 – 159 90 – 99
Stage 2 Moderate 160 – 179 100 – 109

Stage 3 Severe 180 – 209 110 – 119


Stage 4 Severe ≥ 210 ≥ 120

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Types Of Hypertension

According to Pimenta and Oparil (2010), there are three major types of hypertension

These are:

1. Primary Hypertension

2. Secondary Hypertension

3. Malignant Hypertension

1. Primary hypertension:

The primary is also called essential or idiopathic hypertension. The term is used

interchangeably. It normally begins as a benign disease and slowly progresses to an

accelerated or malignant state. It is the most common type of hypertension and accounts for

90 - 95% of all cases of hypertension. Although the exact cause of the type of hypertension is

unknown, there are predisposing factors. These are:

A. Diet

A diet high in sodium (Na+) and saturated fat increases the risk of developing hypertension. A

high intake of sodium such as salt increases blood pressure. Also, intake of high levels of

saturated fatty diet narrows the lumen of the blood vessels due to the formation of atheroma in

the vessels which results in increased blood pressure.

B. Alcohol

Excessive intake of alcohol increases both cardiac output and sympathetic activity which

eventually increases the blood pressure and the peripheral resistance.

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C. Smoking of Tobacco/Cigarette.

Nicotine in tobacco or cigarette have a vasoconstrictive property and this does cause acute

elevations of blood pressure hence, hypertension.

D. Obesity

Weight above desirable levels places extra burden on the heart as it (produces an increase in

the number of smooth muscle cells and a collection of lipids within the intima medium and

large –sized arteries) eventually narrows the Lumina thereby resulting in reduced blood flow

at the distal end of the Artery while pressure is an increased at the proximal end. This process

leads to increased blood pressure.

E. Sedentary lifestyle.

Physical in activity decreases high density lipoproteins, the collateral circulation and vessel

size and increases total cholesterol level, glucose intolerance and body weight. This increase

the risk of developing hypertension.

F. Aging

High blood pressure rises progressively with increasing age .This is because, the number of

collagen fibers in the artery and arterioles walls increases overtime making blood vessels

stiffer. With the reduced elasticity comes a cross - sectional area in systolic and so a raised

mean blood pressure.

G. Family History.

Studies have shown that hypertension is familial thus; persons who are related to hypertensive

patients are at risk of developing hypertension

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H. Race

High blood pressure occurs two to three times more in blacks than in whites, especially at

diastolic levels above105mmhg.

I. Stress.

For instances ,emotional stress triggers the release of fatty acids, glucose and clots promoters

into the blood stream ,when they tend to such in those rips and stick ,helping to form a plaque

.This plaque causes vessels obstruction and structural alteration leading to increased blood

pressure. Also, there is vascular response to sympathetic activation during stress and it is

typically associated with cardiac output which causes an elevation in blood pressure.

J. Sex.

In young adults, hypertension is common among men than women but from age fifty five years

and above it is more common in women.

2. Secondary Hypertension.

a. Renal Disorders

It stimulates the activation of rennin angiotensin aldosterone system resulting in increased

rennin. Subsequently; retention of sodium and water, along with vasoconstriction results in

elevated blood pressure.

b. Cardiovascular Disorders.

For instance, coarctation of the aorta leads to increase pressure in the blood vessels and may

result in hypertension. This usually occurs when the posterior wall of the aorta is thickened

c. Endocrine Disorders.

Elevated level of adrenal cortical hormones can result in blood pressure. Glucorticoid result in

high blood pressure .Both glucocorticoid (cortisol) and these mineral corticoid (aldosterone)

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promote sodium and water retention by the kidney resulting in elevated blood pressure.

Examples of conditions that produce excess of these hormones are primary aldosterone and

Cushing’s syndrome. In addition, hypertension in pregnancy is mainly due to hormonal

disturbance during pregnancy.

d. Neurologic Disorders

Neurologic disorders such as brain tumors and head injuries put pressure on the posterior

Hypothalamus, medulla or nerve pathways leading to excess catecholamine production.

Increase levels of catechol amines cause an increase in cardiac output which may result in

elevated blood pressure

e. Pregnancy

In pregnancy there may also be pregnancy induced hypertension. This usually occurs when

there is abnormal placentation leading to poor placental perfusion. This triggers a

Response in the circulatory system leading to vasospasm and subsequently hypertension.

f. Medication.

Medication such as nervous stimulant oral contraceptive, steroids pills and synthetics in high

blood pressure as part of their side effect.

3. Malignant Hypertension.

It is a severe form of hypertension which usually occurs as a result of poorly controlled blood

pressure. Malignant hypertension is defined as severe hypertension that occurs along with

internal bleeding of the retina in both eyes and swelling of optic nerves behind the retinas. It is

about four times more common in blacks than whites and occurring more in men than in

women. It is especially common in people under 40 years and those of a lower socio-economic

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class. Malignant hypertension is a medical emergency and if left untreated can lead to serious

organ damage or can become rapidly fatal, sometimes even death in three to six month.

Causes of Malignant Hypertension

Like high blood pressure in general, the exact cause of malignant hypertension is not

completely understood. The details of how malignant hypertension starts have been an essential

research topic for many years, and whiles the complete picture is emerging, we do know some

few important things.

 Younger patients are at higher risk than older patients, which is the opposite of the risk

profile for essential hypertension.

 Those of African heritage are at higher risk.

 Anyone with a history of kidney failure or a disease called renal artery stenosis

[narrowing of arteries in the kidney] has a greatly increased risk

 Pregnant women with gestational hypertension or women experiencing certain pregnancy

related complications (toxemia of pregnancy) appear to have an increased risk.

In conclusion, malignant hypertension and the serious nature of the disease, however, make it

an important problem.

Pathophysiology

According to Dominiczak et al., (2010), hypertension is a multifactorial condition. The

regulation of blood pressure is by a complex set of interrelated mechanism that comprises of

the control of vascular tone and sodium and water balance. The overall control of blood

pressure is based on the sympathetic nervous system and the renal rennin-angiotensin system

with cardiac output and peripheral vascular resistance serving as the primary regulatory factor

may lead to an increase in blood pressure. Where there is a decreased blood supply to the

22
kidney such as in renal artery stenosis or condition that alters renal function or failure of any

kind, there is resultant retention of sodium and water through the production of aldosterone

by the kidneys. Also the kidneys release rennin which stimulate angiotensinogen (it is

impotent or inactive in the liver) to angiotensin I. Angiotensin I is in turn converted to

angiotensin II (a potent vasoconstriction agent) by Angiotensin converting Enzyme (ACE).

Angiotensin II constrict several arterioles thus increasing peripheral resistance leading to

hypertension. Conditions like pheochromacytoma (a tumor of the adrenal medulla). Where

adrenalin is secreted by the tumor cells or other conditions that increase intracranial pressure

where pressure on the hypothalamus, medulla and nerve pathways resulting in the production

of excess catecholamine all leads to increase blood pressure. Catecholamine enhances

vasoconstriction and increase cardiac output leading to a corresponding increase in arterial

blood pressure hence hypertension. There is also decreased supply of blood to the brain due

to the constriction of the blood vessels which intend leads to mental confusion, headache and

dizziness as experienced by hypertensive patients.

Hypertension mostly occurs without symptoms, yet can be profoundly damaging to the blood

vessels of major organ systems including the brain, heart and kidneys.

In early phases, few pathologic changes can be found in the structure of the blood vessels

over time, however chronically elevated blood pressure causes widespread pathologic

changes that interfere with effective blood flow especially to the vital organs. Most important

shearing forces from the elevated blood pressure caused by the excess production of

catecholamine damage the intimal layer of the blood vessels, leading to increase fibrin

accumulation and vessels edema. Both the large and small arteries in the body may become

atherosclerotic, tortuous and weak. These changes also narrow the lumen of the blood vessels

thereby decreasing blood flow to the organ or tissue supplied. As the damage progresses, the

vessel can become occluded or even rupture, causing an abrupt cessation of blood flow to the

23
area. Finally, the pathophysiologic changes decrease local auto-regulatory control of blood

flow, as the vessel are less able to control and dilate in response to tissue needs. These greatly

increase the risk for coronary artery disease, cerebrovascular disease, renal artery and

parenchymal disease and peripheral vascular disease.

Clinical Manifestations

According to Hinkle and Cheever (2010), hypertension is usually referred to as the “silent

killer” because it is frequently asymptomatic and usually detected on a routine physical

examination of blood pressure. The signs and symptoms present as;

1. Visual disturbances

2. Epistaxis

3. Dizziness

4. Palpitation

5. Fatigue

6. Body weakness

7. Memory loss

8. Chest pain

9. Dyspnoea

10. Peripheral oedema

11. Seizures

12. Restlessness

13. Weak, peripheral pulse

14. Vomiting

24
15. Coma

16. Haematuria

17. Elevation of blood pressure of 140/90 mmHg or more.

18. Headache

Complications

According to Hinkle and Cheever (2010), hypertension is not identified early for prompt and

effective treatment, it results in complications. These complications usually relates to the

various organs and structures which are dependent to the heart. The organs commonly affected

are;

1. Heart

2. Brain

3. Kidneys

4. Eyes

1.Heart

The excessive workload put on the heart as a result of hypertension makes the heart grow bigger

in size. This is to compensate for the demand put on it. Upon reaching it threshold it results to

conditions such as lift and right heart failure, myocardial infarction, angina pectoris and heart

failure.

2.Brain

Hypertension can lead to cerebrovascular accident or stroke, hypertension encephalopathy and

cerebral aneurysms.

25
3.Kidneys

The elevation of blood pressure caused by hypertension leads to thickening of the arteries. This

affects the blood vessels of the kidneys reducing blood flow through it. This causes loss of

function of the kidney leading to kidney failure.

4.Eyes

Continuous high blood pressure puts strain on the structures of the eyes. This produces changes

in arteries of the eye with damage to the retina and may lead to visual impairment.

Hypertension also changes the nature of the endothelium of blood vessels causing fatty

substances to accumulate in the damaged arterial wall, a condition known as arteriosclerosis.

It also causes abnormal local dilation resulting aneurysms.

Diagnostic Investigations

According to Mish (2016), a diagnostic test is a procedure performed to confirm or determine

the presence of disease in an individual suspected of having the disease, usually following the

report of symptoms, or based on the results of other medical tests.

1. Urinalysis to detect protein, red blood cells and white blood cells suggesting renal disease.

2. Blood chemistry (i.e. analysis of sodium, potassium, fasting glucose and total and high-

density lipoprotein) may be high indicating renal dysfunction.

3. Electrocardiography (ECG) which may reveal left ventricular hypertrophy and also the

electrical activity of the heart.

4. Chest x-ray, this demonstrates cardiomegaly. It may also reveal aortic aneurysm.

5. Excretory urography may reveal renal atrophy indicating chronic renal disease.

6. Monitoring of blood urea nitrogen (BUN and creatinine levels, whether normal or elevated

above 1.5mg/dl which suggest renal disease).

26
7. Urinary catecholamine levels are used to diagnose pheochromacytoma.

Diagnostic Measures

1. Presenting signs and symptoms e.g. Palpitations, fatigue, peripheral edema etc.

2. Physical examination

3. History of patient e.g. a history of hypertension in the family.

Medical Management

According to Smeltzer & Bare (2010), the main objective of any treatment program selected

for individuals is to keep blood pressure within normal range. With the essential hypertension,

there is no specific care rendered but drug therapy, lifestyle modifications and dietary

restrictions as treatment of choice.

Treatment of secondary hypertension is directed towards correcting primary conditions and

curbing hypertension effects.

Pharmacological Management

According to Hinkle and Cheever (2010), the general goal of pharmacological treatment of

hypertension is to reduce and maintain diastolic blood pressure less than 90mmHg and to keep

uncomfortable or disabling side effects of medication to a minimum.

Currently, the available treatment has two main actions:

1. Reduction of systemic vascular resistance

2. Decrease volume of circulating blood

They include;

27
1. Diuretics

This is known to undertake the following functions

a. Decrease sodium in the arterial wall

b. Promote water excretion

c. Reduce plasma volume

d. Reduce vascular response to catecholamine

The common types of diuretics are

i. Loop diuretics

Examples, Furosemide (Laxis) 20 – 80 mg daily

Bumetanide (Bumex) 1 – 5 mg

Torsenide (Demadex)

ii. Potassium – sparing diuretics

Example: Amiloride (Midamor) 5 – 10mg daily, Triamterene 150 -250mg daily , Spiro lactone

(Aldactone)

iii.Thiazides

2. Adrenergic Inhibiting Agent

They act by diminishing the sympathetic reflexes that increases blood pressure. Some of the

types include;

a. Beta adrenergic blockers.

They block the beta – adrenergic receptors of sympathetic nervous system decreasing heart rate

and blood pressure.

28
Examples: Doxazosin (Cardura), Prazosin (Minipress), Herazosin (Hylrin).

b. Peripheral–acting adrenergic antagonist

Deplete catecholamine in peripheral sympathetic postganglionic fibers. Block norepinephrine

release from adrenergic nerve endings.

Examples: Reserpine (serpacil), Guanethedine (ismelin), Guanadre (hylorel)., Methyldopa

(Aldomet)

3 .Vasodilators

Dilate peripheral blood vessels by directly relaxing vascular smooth muscles.

Examples: Hydralazine (apresoline), Minoxidil (loniten)

4. Angiotensin converting enzyme inhibitor

Inhibits converting of angiotensin I to angiotensin II, thus blocking release of aldosterone and

reducing sodium and water retention. Examples: benazepril (lotensin), Captopril (captoten),

Enalapril (Vasotec), Lisinopril (prinevil, zestril)

5. Calcium Channel blockers

Inhibit influx of calcium into muscle cells, act on vascular smooth muscles to reduce spasms

and promote vasodilation; also inhibit calcium movement in heart muscle.

Examples: Nifedipine (Procardia), Felodepine (plendil)

6. Angiotensin receptor blockers

Blocks the action of angiotensin, thereby relaxing muscle cells and also dilating blood vessels.

Eg Losartan, Irbesartan, Valsartan.

29
7. Benzodiazepines:

Works by facilitating the action of Gama amino butyric acid (GABA), an inhibitory

neurotransmitter in the central nervous system. This calms the brain and nerves. Eg

Diazepam.

Other types of drugs that may be ordered include; Analgesics

Example: Aspirin 300mg – 900mg daily, Paracetamol 1g three times daily.

Nursing Management

According to Kaplan (2010), the nursing care of hypertensive patients begin with reassurance

and explanation of the condition to the patient about the causes, prevention, predisposing

factors and side effects of drugs. Knowledge of the disease condition allays anxiety, thereby

reducing the high blood pressure. Nursing management focuses on diet, rest, observation

lifestyle modification, elimination, medication and exercise.

Reassurance

The patient is reassured that with the good nursing interventions, the blood pressure will fall

within normal range so far as she remains in the hospital. This is done to relax patient, win her

cooperation and confidence and also to relieve and prepare her psychologically for what to

expect

Position

Put patient in an upright position to ensure breathing and to expand the chest supported with

back rest and pillows. The patient may also assume a comfortable and more suitable position.

30
Rest and sleep

Ensure enough rest and sleep to enhance relaxation. Patient should be given warm baths, proper

ventilation, ensure that he is neatly laid and made free from creases, ensure that patient gets

adequate rest and sleep.

Observation

Vital signs such as temperature, pulse, respiration and blood pressure should be monitored two

hourly to know the state or condition of patient, as to whether it is deteriorating or progressing

and take appropriate interventions accordingly. Patient is also observed for therapeutic effect

and side effect of drugs as well as the mental orientation of patient to time and place.

Monitoring of patient’s intake and output chart is done and balanced at the end of 24 hours.

Patient is also to be observed for headache, dizziness and palpitations.

Patient can also be observed closely for any stressful events psychological, financial and social

problems.

Personal hygiene

Patient may be assisted to take his or her bath twice daily or given a bed bath in order to remove

dirt, microbes and sweat from the skin, improve circulation for comfort and relaxation

The choice either depends on the severity of the patient’s conditions. Patient’s is also assisted

to wash hair to prevent hair infestation. Hands and feet must also be cared for in order to

prevent them from harboring microbes or injuring patient. Patient’s clothing must be changed

regularly and that includes bed linens and soiled diapers.

Oral care may also be done or the patient assisted to do so if possible

Nutrition

Patient is assisted to meet his nutritional requirement by eating a well – balanced diet that is

low in sodium and fat. Patient should be encouraged to take in vitamin supplement or fruits
31
and vegetables to boost the body’s immune system. Patient should therefore be involved in

planning diet and assisted to adopt the DASH eating plan (Dietary Approaches to Stop

Hypertension). Meals served should be presented attractively and given in small quantities at

regular intervals because the cardiac output tends to increase with the intake of large heavy

meals.

Exercise

Patient is encouraged and assisted if there is the need undertake either passive or active exercise

to his or her tolerance levels, in order to improve circulation and to prevent complications such

as joint stiffness, aid in peristalsis and to prevent constipation.

Assist patient to sit up in bed, walk around the bed and gradual turning in bed.

Elimination

Serve bed pan or assist patient to visit the toilet at patient’s request and urinals served when

necessary. When patient is unable to micturate, nursing measures such as opening for it to run,

applying cold compresses on the abdomen and catheterization carried out as ordered by the

doctor in the extent that all other measures taken to get patient to micturate fails.

Patient and Family Teachings

The diagnosis of hypertension is usually unexpected and asymptomatic. Yet, once the diagnosis

is made, the patient is asked to modify meal patterns and food choices, adopt daily exercise

routine and adhere to the use of new medication with a variety of side effects.

The family and patient is educated on the risk factors, signs and symptoms and management of

hypertension.

They are advised to go for regular checkups and their blood pressure taken since hypertension

is hereditary.

32
Non – Pharmacological Management

According to Kaplan (2010), non-pharmacological management of hypertension include,

o Dietary changes

o Lifestyle modifications

Dietary Changes

1. Sodium intake should be restricted

2. increase fiber intake

3. increase potassium intake as it increases extracellular potassium

4. caloric and fat restriction

5. adequate intake of fruits and vegetables

6. reducing sugar intake

Lifestyle Modification

1. Weight reduction by at least 15 to of the optimum weight.

2. Regular exercise. Regular aerobic exercise such as jogging, walking and swimming can

help control blood pressure. It can cause about 10mmHg decrease in systolic blood

pressure.

3. Avoidance of cigarette smoking

4. Moderation of alcohol intake

5. Stress management(relaxation therapy)

33
Prevention of Hypertension

According to Hinkle and Cheever (2010), hypertension is a life threatening condition and as

such best to prevent its occurrence. A positive outlook towards health is reflected in the

individual’s lifestyle and habits. Health promotion focuses on educating the entire public to

form a positive and more comprehensive attitude towards health.

Primary Prevention

Health education is the most ideal action taken in primary prevention of hypertension. These

thwart the habit or lifestyle of the general public as the causes and effects of hypertension

likewise how the environment becomes a risk factor in the promotion of the disease are taught.

Primary prevention of hypertension includes:

1. Early identification of the condition and providing prompt and appropriate treatment. This

is done through regular screening of individuals to detect any abnormality and if present

prompt doctor’s attention for adequate treatment to be given.

2. Stress management by avoiding unhealthy arguments.

3. Weight reduction

4. Moderation of alcohol intake

5. Avoid smoking cigarette.

6. Regular physical exercise

7. Fat and sodium restriction

Secondary Prevention

This has to do with, prevention of complications of the conditions by using drugs. It can also

be achieved through lifestyle modification.

34
Tertiary Prevention

Tertiary Prevention involves rehabilitation which focuses on assisting the patient to live

independent life after the complication has occurred

Surgical Management

Surgical interventions may become necessary in the case of tumours (pheochromacytoma) and

sclerotic changes of the renal arteries which may be the cause of secondary hypertension. This

surgical intervention is known as adrenalectomy.

Prognosis

Prognosis of hypertension is good if one seeks early medical attention but may worsen if left

untreated for a long time (Hinkle and Cheever, 2010).

1.12 Validation of Data

According to Weller (2009), validation is the extent to which a measure, indicator or a method

of data collection possesses the quality of being true or untrue.

This is to ensure that the data is devoid of errors, relating the signs and symptoms presented by

Mrs. E.A. and the information gathered from her family history and lifestyle and laboratory

investigations carried out corresponds to the literature from selected textbooks confirm that

Mrs. E.A. is actually suffering from hypertension.

35
CHAPTER TWO

ANALYSIS OF DATA COLLECTED

2.0 Introduction

According to Weller (2010), analysis is the study of a whole in terms of its parts.

It is the second phase of the nursing process and it involves the act of deducing fact or

information from data that has been gathered on the patient and his condition in order to arrive

at the needs of the patient and the problems hindering attainment of health and intervening

where necessary to promote health and well-being. It comprises;

1. Comparism of data with standard

2. Patient/Family strength

3. Health problems

4. Nursing diagnosis

2.1 Comparison Of Data With Standards

The results from laboratory investigation, history or signs and symptoms manifested by the

patient are carefully analyzed, comparing them with standard measures to aid in diagnosing the

patient ’s condition.

(A) Diagnostic Investigations/Test

A diagnostic investigation is a procedure performed to confirm or determine the presence of

disease in an individual suspected of having the disease usually following the report of

symptoms or based on the results of other medical tests.

The following diagnostic tests were carried out on patient;

36
1. Full Blood Count

2. Malaria parasite

3. Blood urea electrolyte and creatinine

4. Urinalysis

Table 1 below shows the Comparism of diagnostic tests carried out on Mrs. E.A with those

listed in literature review.

Table 1: Diagnostic tests/investigation in literature review compared with those carried

out on Mrs. E.A

Diagnostic Test Outlined In Literature Diagnostic Test Carried Out On The

Review Patient

Urinalysis to detect protein, red blood cells and Urinalysis was done for patient
white blood cells suggesting renal disease.
Urinary catecholamine levels are used to was not carried out on patient
diagnose pheochromacytoma
Monitoring of blood urea nitrogen (BUN and was not carried out on patient
creatinine levels, whether normal or elevated
above 1.5mg/dl which suggest renal disease.
Excretory urography may reveal renal atrophy was not carried out on patient
indicating chronic renal disease.
Chest x-ray, this demonstrates cardiomegaly. It was not carried out on patient
may also reveal aortic aneurysm.
Electrocardiography (ECG) which may reveal was not carried out on patient
left ventricular hypertrophy and also the
electrical activity of the heart.
Blood chemistry (i.e. analysis of sodium, Fasting blood glucose was not ordered for
potassium, fasting glucose and total and high-
density lipoprotein) may be high indicating patient.
renal dysfunction.

37
Only one diagnostic investigation in the literature review was conducted on Mrs. E.A which

was urinalysis to help confirm the diagnosis and to rule out any complications.

The following tests however, were not pointed out in the literature review but were carried

out on Mrs. E.A.

1. Blood for full blood count

2. Blood film for malaria parasites

Blood for Hemoglobin level estimation was requested and done to know the hemoglobin

level in the system so that if it is low and out of normal, it can be corrected with blood

transfusion. Patient Hemoglobin level was within normal range and there was no need for

transfusion.

Blood film for malaria parasites was also done to know if there were presences of malaria

parasites in her blood, so that treatment can be given, but she tested negative which showed

the absence of malaria parasites in her blood.

Details of the test carried out on patient have been presented in table 3

38
Table 3: Diagnostic Investigations Carried Out On Mrs. E.A

Date Specimen Investigation Result Normal Values Interpretation Remarks


28/00/ Urine Urine routine Sugar Negative Negative Normal No treatment ordered
Ketone Negative Negative Normal No treatment ordered
2018 examination
Bilirubin Negative Negative Normal No treatment ordered
Specific gravity 1.020 1.005-1.030 Normal No treatment ordered
PH 6.0 5.0-8.0 Normal No treatment ordered
Blood Negative Negative Normal No treatment ordered
Protein Negative Negative Negative Antibiotics ordered

Nitrite Negative Negative Normal No treatment ordered


leukocytes Negative (-) Negative Normal Antibiotics ordered
Epithelial cells 4 less than 5 Normal Antibiotics ordered
Pus 1/1 1/1 -Above normal Antibiotics ordered
Colour Straw Straw -Indicates dilution of urine No treatment ordered

39
Table 3: Diagnostic Investigations Carried Out On Mrs. E.A

Date Specimen Investigation Result Normal Values Interpretation Remarks


20/07/2018 Blood Malaria Negative There should be no Normal, no malaria parasite No treatment was given.
parasites malaria parasite in was seen in the blood.
the blood.
20/07/2018 Blood White blood 5.3 x109/L 4.0-10.0 x109/L WBC count was normal. No treatment was
cells Indicating absence of ordered.
infection.

Red blood 4.6 x 10/l 3.9 -6.5 x 10/l No treatment was given
cell count Normal

Neutrophils 46% 40-75% Normal No treatment was given


count
Haemoglobin 13.1 g/dl 11.-16.5g/dl Normal No treatment was given
levels

Hematocrit 42% 40-54% Normal No treatment was given

40
Table 3: Diagnostic Investigations Carried Out On Mrs. E.A
Date Specimen Investigation Result Normal Values Interpretation Remarks

28/09/2018 Blood Blood urea 4.75 2.9 -8.2 mmol/l Within normal range No treatment ordered

28/09/2018 Blood Creatinine 92 41-133 umol/l Within normal range No treatment ordered

41
b. Causes of Patient’s condition

Considering the factors that cause hypertension as indicated in the literature review Mrs.

E.A’s condition is due stress may be a contributive factor since it triggers the sympathetic

nervous system to activate vascular response which is typically associated with cardiac output

and causes an elevation in blood pressure. Her condition can also be said to have been

associated with genetics. This is because her mother and late grandmother had already being

diagnosed with hypertension.

C. Clinical Features /Signs and Symptoms

Comparison of clinical features exhibited by Patient with those listed in the literature review.

Table four below shows the comparison of clinical features.

Table 4: Comparison of Clinical Features in Literature Review with Those Patient

Exhibited

Clinical Features In Literature Clinical Features Exhibited By Patient.

Review

Elevated blood pressure of Patient had a blood pressure of 190/110mmHg

140/90mmHg or more.

Visual disturbances Patient had no visual disturbances

Epistaxis Patient did not experience nasal bleeding

Dizziness Patient complained of dizziness

Palpitations Patient had palpitations

Fatigue Patient experienced fatigue.

Restlessness Patient complained of restlessness

Memory loss Patient had no memory loss

42
Clinical Features In Literature Clinical Features Exhibited By Patient.

Review

Chest pains Patient did not experience chest pains

Dyspnoea Patient had no dyspnea

Peripheral oedema Patient had no peripheral oedema

Seizures Patient did not experience seizures

Vomiting Patient did not experience vomiting

Weak peripheral pulse Patient had no weak peripheral pulse

Haematuria Patient did not experience Heamaturia

Coma Patient did not experience coma

Body weakness Patient experienced weakness

Headache Patient experienced headache

From the comparison in table 4 above, there is clear indication that the patient exhibited some

of the signs and symptoms listed in the literature review, which include, elevated blood

pressure, dizziness, palpitations, fatigue, restlessness, body weakness and headache,

indicating she had hypertension.

However, Patient didn’t manifest the following the clinical manifestations

Epistaxis, visual disturbances, memory loss, chest pains, dyspnoea, peripheral oedema,

seizures, vomiting, weak peripheral pulse, heamaturia and coma because she reported earlier

to the hospital.

D. Treatment
Mrs. E.A was managed on the following drugs throughout admission;

43
Hydralazine hydrochloride (intra venous) 10mg stat

Tab Losartan 100mg daily for 30 days

Tablet Methyldopa 1g twice daily for 30 days

Tablet Bendroflumethiazide 5mg daily x 30

Tablet diazepam 10mg nocte for 5 days

Tablet Aspirin 75mg daily for 14 days

Tablet Paracetamol 1g tds for 5 days

Tablet Amlodipine 10mg daily for 30 days.

Table 5 below shows the treatment given to Patient compared with those in literature review

Table 5: Comparison of treatment outlined in literature review with those ordered for

Mrs. E.A

Treatment Outlined In Literature Review Treatment Given To Patient

Diuretics like furosemide 20-80mg orally Tablet Bendroflumethiazide 5mg daily x 30

Adrenergic inhibiting agent like Prazosin Tablet Methyldopa 1g bd for 30 days was

ordered.

Vasodilators like hydralazine intravenously Hydralazine hydrochloride(intra venous) 5mg

slowly for 15minutes

Angiotensin converting enzyme inhibitor like She was not given lisinopril

lisinopril

Calcium channel blockers like nifedepine Tablet Amlodipine 10mg daily x 30 was

prescribed

Analgesics like aspirin 300-900mg Tablet Paracetamol 1g tid for 5 days

Soluble aspirin 75mg daily x 30

Anxiolytics like diazepam Tablet diazepam 10mg nocturnal x 5

44
From the table above, it can be said that patient received most of the treatment for managing

hypertension. This led to her recovery and prevention of complication.

Table 6, below shows the details of the pharmacology of drugs administered to my patient

during her stay in the hospital.

45
Table 6: Pharmacology of Drugs Given To Mrs. E.A

Date Drug Dosage/route of Classification Desired effect Actual action observed Side effects /Remedies
administration
28/9/18 Tablet 5mg daily x 30 Thiazide diuretics Inhibits sodium High blood pressure Postural hypotension,
Bendroflumethi Oral reabsorption at the distal controlled from
hypernatremia, hypercalcaemia,
azide convoluted tubules. 160/110mmHg to
gout, impaired glucose tolerance,
Increasing the amount of 120/80mmHg as
urine, passed from the evidenced by the hourly impotence, fatigue.
kidneys. blood pressure chart
None was observed on patient
And dilates the vessels as
well.

08/8/16 Tablet 10mg daily × Calcium channel Dilates coronary and Patient’s blood pressure Dizziness, fatigue headache,
Amlodipine 30days oral blocker peripheral arteries reduced from
190/100mmhg to nervousness, peripheral oedema.
120/70mmHg.
None was observed on Patient.

46
Table 6: Pharmacology of Drugs Given To Mrs. E.A continued

Date Drug Dosage/route of Classification Desired effect Actual action observed Side effects /Remedies
administration

28/9/18 Tablet diazepam 10mg Benzodiazepines It induces a calming effect Patient was able to sleep, Drowsiness, fatigue and ataxia. None
daily(nocturnal) × on the thalamus and throughout the night. was observed on patient.
5 days oral hypothalamus

28/9/18 tablet 1g tid for 5 days Analgesic It suppresses production of Headache subsided Jaundice, nausea, loss of appetite,
Paracetamol oral prostaglandins by abdominal upset. None was observed
inactivation cyclooxygenase
thereby reducing pain

29/9/20 Soluble aspirin 75mg daily x 30 Analgesics It suppresses production of Headache subsided Abdominal pain, constipation
18 Oral prostaglandins by diarrhea, fluid retention. None was
observed.
inactivation
cyclooxygenase thereby
reducing pain.
28/9/18 Injection 10mg stat Vasodilator It relaxes and dilates the Patient’s blood pressure Body pain, nausea, shortness of
Hydralazine Intravenous blood vessels in the body, reduced from breath, vision changes , itching,
allowing blood to flow 190/100mmhg to numbness.
120/70mmHg
through the vessels more None was observed on Patient.
easily and at a lower
pressure.

47
Table 6: Pharmacology of Drugs Given To Mrs. E.A continued

Date Drug Dosage/route of Classification Desired effect Actual action observed Side effects /Remedies
administration

28/9/18 Tablet Losartan 100mg daily for Angiotensin Blocks the action of Patient’s blood pressure Body pain, nausea, shortness of
30 days receptor blockers angiotensin, thereby reduced from
breath, vision changes , itching,
orally relaxing muscle cells and 190/100mmhg to
120/70mmHg numbness.
also dilating blood vessels
None was observed on Patient.
28/9/18 tablet 1g bd for 30 Peripheral–acting Deplete catecholamine in Patient’s blood pressure Body pain, nausea, shortness of
methyldopa days peripheral sympathetic reduced from
breath, vision changes , itching,
adrenergic postganglionic fibers. 190/100mmhg to
120/70mmHg numbness.
Block norepinephrine
antagonist
release from adrenergic None was observed on Patient.
nerve endings

48
Complications

With reference to the complications indicated in the literature review such as myocardial

infarction, cerebrovascular accidents, renal failure, Mrs. E.A did not experience any

complication due to effective medical and nursing care rendered during hospitalization.

.2.2 Patients/Family Strengths

A patient and family strengths refers to the factors or activities that can be identified on

a patient irrespective of his/her illness that can help the nurse to plan an individualized

care for the patient. This involves the activities that contribute to the well-being of

patient and his family as well as his speedy recovery.

The following strengths were observed on patient and family during the period of

admission;

1. Patient’s headache reduces when she takes analgesics.

2. Patient’s dizziness subsides with enough bed rest.

3. Patient was able to voice her fears about unknown outcome of disease.

4. Patient’s palpitations reduce with complete bed rest.

5. Patient could sleep for about three (3) hours at night

6. Patient and family were ready and willing to learn about the disease condition.

2.3 Patient/Family’s Health Problems

Weller (2010) defines problems as, any health care condition that requires diagnostic,

therapeutic, or educational action. It also refers, in nursing, to any unmet or partially met

basic human need. The patient/family’s problem means, the difficulties they faced

because of the disease condition .The following were the actual and potential health

problems identified with the patient during the period of hospitalization. They include ;

49
1. Patient complained of headache (28/09/2018)

2. Patient complained of dizziness (28/09/2018)

3. Patient was anxious about outcome of disease condition (28/09/2018)

4. Patient complained of palpitations (28/09/2018)

5. Patient could not sleep well (29/09/2018)

6. Patient had inadequate knowledge on disease condition (30/09/2018)

2.4 Nursing Diagnosis

Nursing diagnosis is a statement of a health problem or of a potential health problem in

the patient’s/Patient’s health status that a nurse is professionally competent to treat.

The following nursing diagnoses were formulated for patient and her family;

1. Acute pain (Headache) related to distension of the cerebral blood vessels

associated with increased vascular pressure (28/09/2018)

2. High risk for injury related to dizziness (28/09/2018)

3. Anxiety related to unknown outcome of condition (hypertension) (28/09/2018)

4. Alteration in body comfort related to palpitations (28/09/2018)

5. Sleep pattern disturbance (Insomnia) related to change of environment

(hospitalization) (29/09/2018)

6. Knowledge deficit related to lack of inadequate information on causes, signs and

symptoms and prevention of disease condition (hypertension) (30/09/2018)

50
CHAPTER THREE

PLANNING OF PATIENT/FAMILY CARE

3.0 Introduction

Planning is the third stage of the nursing process in which the nurse and the patient

together consider the goals to achieve in meeting the patient’s identified or potential

problems in daily life and produce an individual care plan. (Weller, 2009).

In planning, objectives are set and prioritized into short and long term goals. Goals set

are developed upon and a plan of care drawn to resolve the nursing diagnosis within the

stipulated time frame

3.1 Objectives/Outcome Criteria

The following objectives and outcome criteria was set for the patient;

1. Patient will be relieved of headache within 72hours

2. Patient will demonstrate absence of injury throughout hospitalization

3. Patient will be relieved of anxiety within 24 hours

4. Patient will be relieved of palpitations throughout hospitalization

5. Patient will be able to sleep uninterrupted for 6 hours in the night and at least 1

hour in the day within 48hours

6. Patient will gain adequate knowledge on the disease condition within 24 hours

Table seven below shows the nursing care plan for Mrs. .E.A and family

51
Table 7: Nursing Care Plan for Mrs. E.A

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
28/09/18 Acute pain Patient’s will be 1. Reassure patient her headache will 1. Patient reassured that all nursing01/10/18 Goal fully
subside with good care. procedures will be done to ease
11am (Headache) relieved of headache headache 11am met as
2. Assess patient’s level of pain 2. Patient’s level of pain was assess
related to within 72 hours as patient
using a pain rating scale from 0-10
distension of evidenced by; 3. Assist the patient to assume a 3. Patient assisted to lie in a semi – verbalized
comfortable position of her choice and prone position and encouraged to
the cerebral 1. Patient verbalizing encourage her to have enough rest. have enough rest to conserve energy. that she is
4. Apply cold compress on patient’s 4. Cold compresses applied to head
blood vessels that the headache has forehead. to relieve headache and patient relieved of
encouraged to rest.
associated been relieved. headache
5. Ensure quiet environment and dim 5. Quiet environment ensured by
with increased 2. Nurse observing environment. switching lowering the volume of
the television set in the ward and
vascular that the patient has a switching of the light .
6. Prepare a blood pressure chart for 5. Blood pressure chart prepared and
pressure. cheerful facial patient and blood pressure every 4hours blood pressure checked and recorded
and record. every 4hours.
expression
7. Serve prescribed analgesic and 7. Prescribed drugs served e.g.
antihypertensive drugs. Tablet Paracetamol 1g, tab.
Amlodipine 10mg.

52
Table 7: Nursing Care Plan for Mrs. E.A continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
28/09/18 High risk for Patient will 1. Reassure patient that she will be 1. Patient reassured that she will be 03/10/18 Goal fully
demonstrate absence relieved of the dizziness with good relieved of the dizziness with good met as
11am injury related 8am
of injury throughout health care. health care. evidenced
to dizziness
hospitalization as 2. Elevate side rails 2. Side rails were elevated to prevent by patient
evidenced by fall. verbalizing
1.Patient verbalizing 3. Remove all source of injury from 3. All source of injury was removed absence of
absence of dizziness patient eg. needle i.e. sharps e.g. free needles dizziness
2.Nurse observing that 4. Ensure complete bed rest 4. Complete bed rest was ensured and nurse
patient demonstrates 5. Assist patient in self-care activities 5. Patient was assisted in self-care assessing
absence of injury. activities ie.bathing, mouth care that, patient
6. Serve prescribed antihypertensive 6. prescribed antihypertensive and demonstrate
and sedative and monitor patient for sedatives were served e.g. tablet s absence of
side effects of drugs on patient. diazepam 10mg and tablet injury
Nifedipine 20mg
And side effects of drugs was
monitored.

53
Table 7: Nursing Care Plan for Mrs. E.A continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
28/09/18 Anxiety Patient will be relieved 1. Reassure patient about speedy 1.Patient was reassured that, with 29/09/18 Goals fully
recovery. their cooperation and compliance to
11:15am related to of anxiety within treatment regimen, the condition 11:15am met as

twenty four hours (24 can be controlled patient and


unknown
2. Educate patient on the need for 2. Patient was educated on the need
outcome of hours) as evidenced by; hospitalization. for hospitalization family
3. Explain all procedures that will be 3. Procedures that were performed
disease 1.The nurse observing verbalizing
performed on the patient to her on the patient were explained to her
patient having a to gain her cooperation they are not
condition 4. Encourage patient to ask questions 4. Patient was encouraged to ask
cheerful facial about condition. questions about condition. anxious
5. Provide simple and straight forward 5. Simple and straight forward
expression. answers to their questions promptly and answers were given to their
2. Patient verbalizing tactfully. questions promptly and tactfully.
6.Introduce to her other patients who 6.Other patient’s recovering from
they are no more have suffered from the same condition the same condition was introduced
and are recovering to her
anxious
7. Monitor physiological responses, 7.Physiological response such as
such as tachypnea, palpitations, palpitations, headache, restlessness
dizziness, headache, tingling etc was observed for the degree of
sensations, and behavioral cues, such as fear and anxiety patient was facing
restlessness

54
Table 7: Nursing Care Plan for Mrs. E.A continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
28/09/18 Alteration Patient and will be 1. Reassure patient and relative that 1. Patient was reassured that 03/09/18 Goal fully
relieved of palpitation palpitations will stop with good nursing palpitations will stop with good met as
11:15am in body 8am
throughout care. nursing care. evidenced
comfort
hospitalization as 2.Ensure calm restful environment 2.Calm restful environment was by Patient
related to evidenced by ensured verbalizing
1.Patient verbalizing 3. Limit the number of visitors and 3. Number and length of visitors absence of
palpitations
absence of palpitations length of visit. was limited. palpitations
and 4.Maintain activity restriction during 4.Activity was restricted during and nursing
2.Nurse assessing that, crisis crises that the
Patient’s radial pulse 5.Ensure enough bed rest 5.Enough bed rest ensured radial pulse
reads within normal 6.Teach patient relaxing techniques 6. Patient was taught relaxation reads within
range(60-80bpm) techniques. the normal
7.Serve prescribed medications and 7. Prescribed antihypertensive, range (60-
monitor side effects of medications. sedatives etc. served and side 80bpm)
effects monitored.

55
Table 7: Nursing Care Plan for Mrs. E.A continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
29/09/18 Sleep pattern Patient will be able to 1. Reassure patient that with good 1. Patient reassured that with good 01/10/18 Goal fully
sleep uninterrupted nursing care she will be able to sleep. nursing care she will be able to sleep. met as nurse
8am disturbance 8am
for 6 hours in the 2. Lay bed devoid of creases and 2. Bed laid devoid of creases and observing
(Insomnia)
night and at least 1 make patient comfortable in bed. patient made comfortable in bed. that patient
related to hour in the day within 3. Provide a noise free environment 3. Noise free environment provided has been
48 hours as by switching off nearby televisions able to sleep
change of
evidenced by; and restricting visitors. 6hours at
environment
1. Patient verbalizing 4. Provide proper ventilation. 4. Proper ventilation provided by night and
(hospitalization) that she can sleep opening nearby windows and 1hour in the
uninterrupted for 6 switching on fans. day and
hours at night and 1 5. Give warm bath and serve warm 5. Warm bath given and warm drinks patient
hour in the day. drinks served eg. Warm milo drink. verbalizing
2. Nurse observing 6. Serve prescribed drug E.g. tablet 6. Prescribed drugs or medication that she was
that patient can sleep paracetamol 1g, tablet diazepam, served e.g. tablet paracetamol 1g, able to
uninterrupted for 6 tablet amlodipine tablet diazepam, tablet amlodipine sleep.
hours in the night and
1 hour in the day.

56
Table 7: Nursing Care Plan for Mrs. E.A continued

Date/ Nursing Objective/ Outcome Nursing Orders Nursing Intervention Date/ Evaluation Sign
Time Diagnosis Criteria Time
30/09/18 Knowledge Patient will gain 1. Reassure patient /family that with 1. Patient /family was reassured that 01/09/18 Goal fully
deficit related to detailed information they will have detailed information on met as
adequate knowledge
9am lack of understanding of hypertension hypertension will be given for 9am patient and
inadequate on the disease family give
better understanding.
information on correct
condition within 24 2. Schedule time with patient and 2. Time was scheduled with patient
causes, signs answers to
and symptoms hours as evidenced relatives to educate them on and relatives to educate them on questions
and prevention hypertension. hypertension. asked on
by;
of disease 3. Make patient comfortable by lying 3. Patient was made comfortable by hypertension
condition 1. Patient / family in bed whiles relatives and the lying in bed whiles relatives and correctly and
(hypertension) nurse sit by bedside. the nurse sit by bedside. .patient/
being able to answer
family
4. Assess patient and family 4. Patient and family knowledge on
some questions on verbalizing
knowledge level on hypertension hypertension was assessed. understandin
hypertension 5. Correct any misconception and 5. Accurate information on the g on the
correctly and provide accurate information on the predisposing causes, signs and information
predisposing causes, signs and symptoms, prevention, drug given them
2.Patient/family
symptoms, prevention, drug management and lifestyle
verbalizing management and lifestyle modification were provided to
understanding on the modification correct misconceptions
information given 6. Invite questions and answer them 6. Questions were invited and
tactfully. tactfully answered.
them.
7. Give patient pamphlets on 7. Pamphlets on hypertension were
hypertension to read given to patient

57
CHAPTER FOUR

IMPLEMENTING PATIENT/ FAMILY CARE PLAN

4.0 Introduction

Implementing is the fourth stage in the nursing process. It gives a vivid account of the actual

nursing care given to the patient / family from the day of admission till his discharge based

on the health problems identified. It also deals with the home visits and follow-ups to ensure

continuity of care.

4.1 Summary of Actual Nursing Care Rendered To Patient and Family

The actual nursing care rendered to patient and his family commence on the day of

admission, 28/09/2019 to the time care was terminated. The management of patient and her

family was planned to meet their physiological, psychological, emotional and spiritual needs.

First Day of Admission (28/09/2018)

Mrs. E.A was admitted to the females’ ward of the St. Theresah’s’ Hospital per ambulatory

on the 28/09/2018 at 10:30am from the outpatient department accompanied by an OPD

nurse. They were warmly welcome and seat was offered. Patient’s folder was collected from

the OPD nurse and her name was mentioned to ascertain and confirm the identity of the

patient. Mrs. E.A was immediately made comfortable in an already prepared admission bed

in female’s ward with bed number FW-2 because she complained of dizziness. I introduced

myself and the staff around to the patient. Mrs. E.A’s particulars were documented into the

admission and discharge book and daily ward state. Upon assessment patient looked ill. She

complained of dizziness, headache and palpitations. Patient was confirmed to be anxious

also.

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Her vital signs were checked and recorded as follows

Temperature - 36.9oc

Pulse - 84bpm

Respiration - 21cbm

Blood Pressure - 190/110mmHg

SPO2 - 97%

Laboratory investigations requested on admission were

Blood for Full blood count

Blood for malaria parasite

Blood for blood urea and creatinine

Urine for urinalysis

Blood sample was taken, sample bottle labelled and sent to the laboratory for the

investigations to be carried out.

On admission patient was managed on the following medications;

Intravenous Hydralazine 10mg stat

Tablet Losartan 100mg daily for 30 days

Tablet Methyldopa 1g bd for 30 days

Tablet Bendroflumethiazide 5mg daily x 30

Tablet Amlodipine 10mg daily for 30 days

59
Drugs were immediately procured from the pharmacy department. An intravenous cannula

was established and due medication was administered as prescribed. Other medical orders

such as hourly blood pressure monitoring, complete bed rest and education of patient on

condition were all carried out.

Patient was then orientated to ward and its environs such as the toilet, bath room and the

nurses station. They were also introduced to the other patients on the ward. Since the ward

didn’t not have a dining hall, patient was encouraged to eat by the bed side. She was also

told of the visiting hours of the hospital. Patient was encouraged to call home for them to

bring patient’s personal items that she may need at the ward such as towel, sponge, tooth

brush, toothpaste and bucket from the house. She was asked to talk to any of the nurses

around if she needed anything or help.

After these interventions, I told the ward in-charge of my intention of using the patient and

the family for a case study and I was given the permission. I introduced myself to the patient

again that, I am a student nurse of Nurses’ Training College, Sampa, who was conducting a

care study at the hospital. I then made it known to Mrs. E.A of my desire to give her a

special nursing care for her speedy recovery. She was told that, as part of my training, final

year students are to take a patient each, nurse him or her from the time of admission till time

of discharge and home visits. Mrs. E.A accepted and promised her cooperation and readiness

to give me any information needed for my study. She was told that, she would be discharged

home once her condition was stable and that she were not going to be on the ward forever.

She was also informed that, as part of my care, I would visit their home whiles she was on

admission and after she has been discharged. I promised to keep the data that give out with

utmost confidentiality.

60
After the initial care rendered, patient was assessed intensely to identify her health problems in

order for care plan to be drawn for her.

At 11am, Mrs. E.A complain of headache. A nursing diagnosis of acute pain (Headache)

related to distension of the cerebral blood vessels associated with increased vascular pressure

was formulated. An objective was set to be met in 72 hours to ensure patient was relieved of

headache. The interventions carried out to achieve the goal set were; Patient was reassured

that all nursing procedures will be done to ease headache. Patient’s level of pain was assess

using a pain rating scale from 0-10. Patient was then assisted to lie in a semi –prone position

and encouraged to have enough rest to conserve energy. Also, cold compresses were applied

to her head to relieve headache and quiet environment ensured by switching lowering the

volume of the television set in the ward and switching off the light to provide a dim

environment. Blood pressure chart was prepared and blood pressure checked and recorded

every 4hours. Prescribed drugs served e.g. Tablet Paracetamol 1g, tab. Amlodipine 10mg, IV

hydralazine 10mg stat were administered and it’s therapeutic effects observed.

Also at 11am, patient complain of dizziness. A nursing diagnosis of high risk for injury

related to dizziness was formulated. An objective was set to ensure patient was free from

injury till she was discharged. Nursing orders carried out were; Patient was reassured that she

will be relieved of the dizziness with good health care been rendered. Side rails were elevated

to prevent fall and all source of injury was removed i.e. sharps e.g. free needles. Complete

bed rest was ensure and patient was assisted in self-care activities ie. Bathing, mouth care.

Prescribed antihypertensive and sedatives were served e.g. tablet diazepam 10mg and tablet

Nifedipine 20mg and side effects of drugs was monitored.

Moreover at 11:15am of the day of admission, patient was observed to be anxious. An

objective was set to help relieve patient of anxiety within 24hours. In order to achieve the

61
goal set, Patient was reassured that, with their cooperation and compliance to treatment

regimen, the condition can be controlled. Patient was educated on the need for hospitalization

and nursing procedures that were performed on the patient were explained to her to gain her

cooperation .Patient was then encouraged to ask questions about hypertension. Simple and

straight forward answers were provided to her questions promptly and tactfully. Other

patients recovering from the same condition were introduced to her. Physiological response

such as palpitations, headache, restlessness etc. was observed for the degree of fear and

anxiety patient was facing.

Moreover, on the day on admission at 11:15am, Mrs. E.A complain of palpitations. Alteration

in body comfort related to palpitations was formulated as a nursing diagnosis. An objective

was set to ensure patient was relived of palpitations throughout the period of admission.

Nursing interventions carried out were; patient was reassured that palpitations will stop with

good nursing care. Calm restful environment was ensured. Number and length of visitors was

limited. Activity was restricted during crises as patient was encouraged to rest and relax. And

also enough bed rest ensured. Patient was taught relaxation techniques. Vital signs were

checked and recorded especially the value of pulse was noted and charted appropriately.

Prescribed antihypertensive, sedatives etc. served and side effects monitored.

At 2pm vital signs was checked and recorded as

Temperature 35.7oc

Pulse 120

Respiration 28

B.P 180/90mmHg

SPO2 96%

62
Patient had yam and garden eggs stew for lunch.

During the visiting hours, patient was visited by her apprentices, who had brought her the

personal items she was going to need at home. Patient’s mother too came around to take care

of her. Her husband Mr. A.M.K also came to visit and brought along their son who had

closed from school. Mr. A.M.K brought her drinks and other items such as milo, bread and

milk. I introduced myself to patient’s mother and her husband. The husband and their son left

for home after the visiting hours, with her mother remaining behind to take care of her.

At 6pm, Mrs. E.A had banku with groundnut soup as supper. Vital signs was checked and

charted at 6pm. Due medications were served at 8pm. Patient was encouraged to have warm

bath and perform oral hygiene to aid her in sleeping.

Patient retired to bed at 10pm and she was duly handed over to night staff.

Second Day of Admission (29/09/2018)

According to the night nurses patient had interrupted sleep pattern. This was confirmed by

patient herself, who said she could not sleep very well. Patient finally woke up at 5:30am. Her

personal hygiene activities such as brushing of her teeth, bathing, toileting and grooming were

all done in the morning without assistance. During the morning visiting time, patient was

visited by Mr. A.M.K (patient’s husband). Patient had bread and milo beverage as breakfast.

Morning vital signs were checked and recorded at 6am as;

Temperature 36.7 degrees celsius

Pulse 88 beats per minute

Respiration 20 cycles per minute

Blood pressure 130/90 mmHg

SPO2 99%

63
Morning medications included Tablet Losartan 100mg, Tablet Methyldopa 1g, Tablet

Bendroflumethiazide 5mg and Tablet Amlodipine 10mg were all served and the therapeutic

and side effects observed.

At 8am during interaction with patient, it was identified that patient had insomnia. A nursing

diagnosis of Sleep pattern disturbance (Insomnia) related to change of environment

(hospitalization). An objective was set to help patient sleep well within 48 hours.

Interventions carried out were; Patient was reassured that with good nursing care she will be

able to sleep and bed was laid devoid of creases, cramps and patient was made comfortable in

bed. Noise free environment provided by switching off nearby televisions and restricting

visitors. Proper ventilation provided by opening nearby windows and switching on fans.

Warm bath given and warm drinks served eg. Warm milo drink. Prescribed drugs or

medication served e.g. tablet paracetamol 1g, tablet diazepam, tablet amlodipine and the side

effects were monitored.

At 9am, ward rounds was conducted by Dr. Adu Brobbey. Patient’s laboratory investigations

such as urinalysis, full blood count, BUE, creatinine and malaria parasite were all reviewed.

The results from the laboratory investigations were all normal. Patient still continue of

headache and dizziness. Patient was to continue her medications since patient’s blood

pressure had dwindled from 190/100mmHg to 130/90mmHg. Patient’s blood pressure was to

be monitored every four hourly. Vital signs was checked and recorded at 10am and recorded

accordingly.

Patient was encouraged to rest. At 11:15am, the objective set to ensure patient was relieved

of anxiety was evaluated. Goal was fully met as patient verbalised that she was no more

anxious about the prognosis of the disease. All other nursing interventions to ensure

64
Mrs. E.A’s headache subsided, free from dizziness, palpitations and was able to sleep well

were all continued.

Patient was fed with banku and okro soup in the afternoon. Patient was able to eat well. Vital

signs was checked and recorded at 2pm. Patient was encouraged to take a nap in the

afternoon.

Patient was fed with rice and tomato stew and egg. Patient took her bath and joined the other

patients at the ward who were watching “Kuch rang” on adom television. Vital signs were

checked and charted and medications were served at 10pm. She retired to bed afterwards.

Third day on admission (30/09/2018)

On this day, patient woke up about 5:30am, brushed her teeth and took her bath and emptied

her bowel. Her bed was laid and the locker cleaned. Patient and the night nurse affirmed that

patient had a good night sleep with no complaints. Patient was visited by members of her

church during the morning visiting hours. They prayed for her. Mrs. E.A was happy they

visited her. Her vital signs were checked and recorded in the vital sign chart at 6:30am as;

Blood pressure 150/90mmHg

Temperature 36.70c

Pulse rate 87bpm

Respiration 24cpm

After the vital signs, patient was served with breakfast which was corn porridge and bread.

Due medications such as Tablet Losartan 100mg, Tablet Methyldopa 1g, Tablet

Bendroflumethiazide 5mg and Tablet Amlodipine 10mg were all served and the therapeutic

and side effects observed.

65
Ward rounds was conducted by Dr. Adu. Tablet Diazepam 10mg nocte daily for 5 days,

Tablet Soluble Aspirin 75mg daily for 14 days were added to patient’s treatment plan. The

drugs were attained from the pharmacy and served accordingly.

At 9am, during interaction with patient, it was realised patient had limited knowledge on her

disease condition. Nursing diagnosis of knowledge deficit related to lack of inadequate

information on causes, signs and symptoms and prevention of disease condition. An objective

was set to ensure patient had adequate knowledge on the disease condition within 24 hours.

Nursing orders carried out included Patient and family were reassured that detailed information

on hypertension will be given for better understanding. Time was scheduled with patient and

relatives to educate them on hypertension. Patient was then made comfortable by lying in bed

whiles relatives and the nurse sat by bedside. Patient and family knowledge on hypertension

was assessed. Accurate information on the predisposing causes, signs and symptoms,

prevention, drug management and lifestyle modification were provided to correct

misconceptions. Questions were invited and tactfully answered. Finally, pamphlets on

hypertension were given to patient to ensure she is able to refer from it even when she is

discharged.

All other nursing interventions to ensure Mrs. E.A’s headache subsided, free from dizziness,

palpitations and was able to sleep well were all continued.

Vital signs was checked and recorded at 2pm. Tablet paracetamol 1g was also served at 2pm.

Patient had fufu with beef for lunch. Patient was able to eat well.

At 6pm, patient had rice and kontomire stew for supper. She was able to eat half of the food

served to her. Evening medications were then served and patient was encouraged to take her

evening bath. After that, vital signs were checked and recorded and tablet diazepam 10mg

was administered at 10pm. Patient then retired to bed at around 10:30pm

66
Fourth day of admission (01/10/2018)

On the fourth day of admission, Mrs. A.O woke up at 5:20 am, performed oral hygiene and

took her bath. Patient looked very cheerful and relaxed. Patient did not lodged any complain.

Patient took porridge and bread as her breakfast.

Patient’s condition was good since the problems which were identified were all being worked

on so as to relieve her of all of them and possibly prevent complications from setting in.

At 6:00 am patient’s vital signs were checked and recorded as follows;

Temperature 35.7 degrees celsius

Pulse 78 beats per minute

Respiration 20 cycles per minute

Blood pressure 150/90 mmHg

SPO2 98%

Due medications served were Tablet Losartan 100mg, Tablet Methyldopa 1g, Tablet

Bendroflumethiazide 5mg, Tablet Soluble Aspirin 75mg and Tablet Amlodipine 10mg.

At 8am, goal set to ensure patient was able to sleep well was evaluated. Goal was fully met as

Mrs. E.A verbalised that she slept uninterrupted in the night and could now sleep at least 1

hour in the afternoon.

Also, patient assessed to evaluate the goal set to ensure patient had adequate knowledge on

disease condition. Goal was also fully met as Mrs. E.A was able to answer questions on the

causes, signs, symptoms and treatment plan for hypertension.

Routine ward rounds was conducted by Dr. Adu. No new complains were lodged by patient.

Due to this no knew treatment was added to patient’s treatment plan.

67
After the ward rounds, patient was informed of my intention to visit her house the next day.

She readily accepted and gave me directions to her house. Patient claimed her house was very

easy to locate and it was at a very popular place also.

At 11am, patient was assessed to evaluate the objective set to ensure patient was relieved of

headache. Goal was fully met as patient verbalised absence of headache. Vital signs was

monitored at 2pm and 10pm with no abnormalities and they were duly recorded. Patient took

fufu and groundnut soup as her supper. Evening medications were served and patient retired to

bed after taking her bath.

Fifth day of admission (02/09/2018)

Mrs. E.A looked cheerful and relaxed than she did on admission. She maintained her personal

hygiene that is brushing her teeth and taking her bath. Patient groomed herself and changed

into a nice straight dress. Her bed linen were changed to make her comfortable.

Her vital signs checked at 6:00am were recorded in the nurse’s notes as follows:

Temperature -36.3oC

Pulse – 80 beats per minute

Respiration – 20 cycle per minute

Blood pressure – 120/90mmHg

Her morning medications were charted and recorded on the medication sheet and its therapeutic

effects observed. Patient lodged no complain and had weanimix and bread for breakfast.

Ward rounds was conducted by Dr. Adu and patient was informed that if everything went well,

patient will be discharged the following day. Client was happy.

68
At 11am, Mrs. E.A was informed that I was going to visit her house. She gave me the directions

to her house again and also gave me the phone number of her husband, Mr. A.M.K who she

said was at home. I left the hospital premises to visit the house at 11am.

At 12:30pm, I returned from the home visit. At 2pm her vital signs were checked and the

following readings were recorded in the nurses’ notes:

At 6pm, B.P checked and recorded was 120/80 mmHg. She was served with yam and fish

stew for supper. She was able to eat almost all the slices of yam served. She was encouraged

to watch television. Tablet Diazepam was served at 10pm and vital signs was checked na d

recorded before patient retired to bed afterwards.

Sixth day of admission (Day of discharge) 03/10/2018

On the fourth day of her admission in the ward, Mrs. E.A woke up at around 5:50am looked

strong and very cheerful. She maintained her personal hygiene and took her breakfast. Mrs.

E.A groomed herself. Her bed was laid. Client lodged no complains during the night.

According to the night nurses, patient was able to sleep very well.

Her vital signs checked at 6:00am were recorded in the nurse’s notes as follows:

Temperature -36.3oC

Pulse – 80 beats per minute

Respiration – 20 cycle per minute

Blood pressure – 120/90mmHg

She was served with white porridge and milk with bread as breakfast of which she was able

to eat very well.

69
At 8: 00am, the following medication were also served and recorded on the treatment sheet:

Tablet Losartan 100mg, Tablet Aspirin 75mg, Tablet Methyldopa 1g, Tablet

Bendroflumethiazide 5mg and Tablet Amlodipine 10mg. Patient verbalising her readiness to

be discharged.

At 8am Mrs. E.A was assessed to evaluate goals set to ensure patient was free from injury

due to dizziness and also palpitations. Goal was fully met as patient was free from injury and

patient also verbalised absence of palpitations.

At 9am, ward rounds was conducted by Dr. Adu and patient lodged no complain. Upon

review of patient’s blood pressure pattern by the medical doctor, patient was duly discharged.

Patient was to come for review after one week. She was discharged on the drugs that she was

already on at the hospital. Patient called his husband, Mr. A.M.K and informed him that she

had being discharged. Mr. A.M.K came to the ward after 5 minutes.

Mrs. A.O. was scheduled to come back for review on 10/10/ 2018 and was encouraged on the

need for the review. Patient was encouraged to report to the hospital earlier than the scheduled

review date if she feels the condition was relapsing. Arrangements were made with patient and

her family about my second home visit on the 07/10/ 2018.The doctor prepared and signed the

discharge summary. Patient’s date of discharge, diagnosis and state of his condition were

entered into the Admission and Discharge book and daily census sheet. I helped them to pack

their belongings. Mrs. E.A’s folder was sent to the accounts and billing office for clearance.

Since patient is holder of the national health insurance scheme, patient only had to pay 7ghc as

per the hospital’s policy. Patient and family thanked the staff and the student nurses on duty

for her quick recovery. They were then accompanied to the road side. They took a taxi and I

bade them goodbye. The bed linen was removed and discarded into a receptacle to be taken to

70
the laundry and the bed was disinfected as well as the side locker with a 0.5% bleach solution

and left dry.

4.2. Preparation of Patient/ Family For Discharged and Rehabilitation

Preparation of Mrs. E.A and her family for discharge and rehabilitation started on the first

day of admission. The primary aim was to enable him to take active role in her care for

speedy recovery and also to give him an insight into her condition. Emphasis was placed on

the need to visit the hospital immediately when illness occurs, so as to promote early

detection and treatment, to avoid complications. The patient and family were educated on the

following;

1. Diet

They were educated on the importance of a well-balanced diet. She was encouraged to continue

with low salt diet, fruits and adequate fluid intake to prevent constipation, and finally limit the

intake of fatty foods.

2. Personal and Environmental Hygiene

Patient and her family were educated to maintain good personal and environmental

cleanliness. He was advised on twice daily bath, washing of clothes frequently, proper

disposal of refuse, weeding around the compound, and also avoids stagnant waters around

their house.

3. Modification of Life Style

Patient was educated on the need to continue with the low salt diets, avoid high intake of fatty

food, and avoid strenuous exercise. She was encouraged to continue with the active exercise at

home and also adapt the habit of taking more fruits. I also encouraged her not to take alcohol

and also avoid smoking.

71
4. Stress Tolerance / Management.

Mrs. E.A was educated on the management of stress to reduce hypertension. She was advised

to prevent stressful situations and share problems with her husband. She was also made to

understand that, she could also contact someone she trusts for advice when she encounters any

problem rather than keeping it to himself and avoid stress.

5. Drugs and Review

Patient was advised to continue with the medication or treatment regimen as prescribed to

prevent relapse of the disease condition. The side effects of the drugs were explained to them.

She was told to visit the nearest clinic or report to hospital when symptoms reoccur and come

for review as told.

4.3. Follow Up/Home Visit/ Continuity of Care

This is a visit to the patient’s home before and after discharge to find out the actual and

potential problems that contributed to the patient’s illness and also to find ways of solving

them. Assessment is also done to know his response to treatment after leaving the hospital.

Also help in validation of data collecting from patient and family.

First Home Visit (02/09/2018)

Patient was pre informed of the decision to visit her house on the 01/09/2018. She gave me the

directions to her house. On 02/09/2018, the first home visit was made to patient’s house while

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

contributed to the patient’s illness and find ways of solving them before the patient was

discharged as well as factors that contribute to good health and also to validate data obtained

72
from patient and family. I set off from the hospital at 11am after informing patient. She gave

me the number of her husband, Mr. A.M.K who did not go to work that day.

I took a car to the point four junction, around the “masalachi” area. The house is about 5

minutes walk from the road. Patient’s house was easily located as she vividly described it. Mrs.

E.A’ house number is NDA-304. The house is a four room self-contain house with fence wall

around it. It has ornamental flowers grown around the house. The house is built of blocked and

roofed with iron sheets. There is fence around the around and the house is painted only in the

inside and not the outside.

The house share boundaries with about three houses and none of them has a fence. I knocked

on the gate of the house and I was welcome by a voice which was that of Mr. A.M.K. He

warmly welcomed me and offered a seat. The reason for the visit was explained to him. He

said the wife had told him I will be visiting their house and as such he didn’t go to work to be

in the house to receive me. The house has four bed rooms, a hall, toilet, bathroom and a

kitchen. The house is occupied by two other people who are tenants. Even though the house

has access to pipe born water, Mrs. .EA. has a large barrel in which they temporarily store

water. The barrel had a well fitted lid. They also have a plastic rubber with well fitted lid in

which they keep their refuse. The method of refuse disposal is dumping which is used by the

entire community and it’s about 500metres away from their house. I educated him on water,

food and environmental hygiene to help them improve their health. I asked permission to enter

the room and it was given. It was realised that their room didn’t have mosquito net but was

well ventilated because it had enough windows. Mr. A.M.K was educated on the importance of

the usage of mosquito nets. Inquiry was made from Mr. A.M.K as to who always sweep the

house and it environ. Mr. A.M.K said because the other rooms are occupied by male tenants,

Mrs. E.A always sweep the whole compound. He was educated to take part of the cleaning of

the house and it’s environ when Mrs. E.A is discharged to ensure she has enough rest and is

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able to recover well. After the interaction, I sought permission to leave and he saw me off. I

walked to the road side and boarded a taxi back to the hospital to continue care of patient.

Second Home visit (07/10/2018).

On the 07/10/ 2018, the second home visit was made to Mrs. E.A’s home. The objective of the

visit was to assess the health status of the patient after discharge, to remind patient and family

of review date/day, to find out whether what I said during the first home visit had been put into

action and to stress on the need for completion of treatment regimen.

I got to the house at 3:30 pm and met Mrs. E.A alone in the house. I was welcomed and she

offered me a seat and I thanked her. She asked of my mission, and I said I was there to check

on her and assess her condition at home and to make sure she was taken her medications as

prescribed. When I inquired about Mr. A.M.K, Mrs. E. A. said her husband had gone to work

and will be home soon. I assessed her to find out if she was still experiencing dizziness,

headache or palpitations. Patient said she was not feeling any pain or dizziness. Because I

carried along an electronic blood pressure apparatus with me, her blood pressure was checked.

Blood pressure was 130/80mmHg. Her general condition was assessed. Mrs. E.A.’s condition

was fair and stable. Her medications were inspected and it was found that she had being taking

her drugs as prescribed. Patient was then congratulated and she was encouraged to take the

remaining medications as prescribed. She was advised to take rest adequately and also dietary

advice was given to her. Patient encouraged to limit the amount of salt she takes. I reminded

her again on also the review date as scheduled on 10/10/2018. Mrs. E.A. promised to come for

review as scheduled. Mrs. E.A., she will be handed over to a community health nurse during

the next visit for continuity of care. After chatting for about thirty minutes, I sought permission

to leave. She escorted me to the road where I took a taxi.

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Review day(10/10/2018)

On day of review, 10/10/2018, patient came to the hospital alone. She reported around 9:15am.

She looked cheerful and had relaxed facial expression. Patient said she went to her shop to

open it and after that came to the hospital.

Mrs. E.A was assisted to collect her folder and her vital signs were checked and recorded as

Temperature-36.7 degrees celsius

Pulse-76bpm

Respiration-20cpm

B.P.-130/70mmHg

Patient was then accompanied to see medical officer for review. On examination and

interaction with the doctor, the patient made no complains. She was encouraged to finish her

medications as prescribed. Tablet Amlodipine 10mg for 30 days, Tablet Losartan 100mg for

30 days, Tablet Methyldopa 1g for 30 days and Tablet Bendroflumethiazide 2.5mg daily for

30 days were all prescribed for patient. Patient was to check her blood pressure every two

weeks and to adhere to dietary management. She was encouraged to avoid stressful

situations, eating fatty diet, taking alcoholic beverages and too much salt, and also avoid

eating too late in the night.

After the review, patient was escorted to the road side to pick a car home. She was reminded

of the next home visit. She was told that she will be handed over to a community health nurse

and care with her and the family will be duly terminated.

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Third home visit (14/10/2018)

Mrs. E.A was visited for the last time on the 14/10/2018. The aim if the visit was to terminate

care with my patient and family and also to handover to a community health nurse for the

continuity of the care.

At 11am, I went to the public health unit of the Ghana health service. I informed their

incharge of my aim. She allocated to me a community health nurse, Mrs. Falilatu, who is the

community health nurse who oversee the area where patient lives. We left for the home of

Mrs. E.A. At 11:30am, we arrived at the home of Mrs. E.A. This time Mr. A.M.K was home.

We were welcomed and seats were offered. The mission for the visit was asked. They were

told then aim for the visit was to handover Mrs. E.A to community health nurse for continuity

of care and to terminate care. Patient’s drug were inspected to identify if she was duly taking

them as prescribed. Mrs. E.A had no complains upon assessment. Her blood pressure read

130/80mmHg. Since it was the last visit, highlight on the various health education given

already was stressed. They were grateful and promised to adhere to the education. Mr. A.M.K

thanked me profusely for the care rendered to his wife from the period of admission to this

day. I therefore introduce the community health nurse to patient and family. She told them

that she will be paying them home visit and she will be continuing the health care which was

been rendered. I used this opportunity to thank them for giving me the chance to use them for

the patient and family care study. After the interaction, we bade them goodbye and they

escorted me to the station to take a car. Care was officially terminated.

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CHAPTER FIVE

EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY

5.0 Introduction

Evaluation is assessment of the patient’s position on the health/illness continuum, and of

effectiveness of patient care activities in bringing about a change in the patient’s position. .

(Weller, 2009).

This chapter gives information about the statement of evaluation, amendment of nursing

goals and the termination of care rendered to the patient and family. It is the final stage of

nursing process.

5.1 Statement of Evaluation

During the admission and hospitalization of Mrs. E.A, six (6) problems were identified and
objectives were set for them. The outcomes of the objectives set for the problems identified
are below:

Patient was relieved of pain (headache) within 72 hours

On the day of admission at 11am, Mrs. E.A complain of headache. A nursing diagnosis of

acute pain (Headache) related to distension of the cerebral blood vessels associated with

increased vascular pressure was formulated. An objective was set to be met in 72 hours to

ensure patient was relieved of headache. The interventions carried out to achieve the goal set

were; Patient was reassured that all nursing procedures will be done to ease headache.

Patient’s level of pain was assess using a pain rating scale from 0-10. Patient was then

assisted to lie in a semi –prone position and encouraged to have enough rest to conserve

energy. Also, cold compresses were applied to her head to relieve headache and quiet

environment ensured by switching lowering the volume of the television set in the ward and

77
switching off the light to provide a dim environment. Blood pressure chart was prepared and

blood pressure checked and recorded every 4hours. Prescribed drugs served e.g. Tablet

Paracetamol 1g, tab. Amlodipine 10mg, IV hydralazine 10mg stat were administered and it’s

therapeutic effects observed.

On the 01/10/2018, at 11am, patient was assessed to evaluate the objective set to ensure

patient was relieved of headache. Goal was fully met as patient verbalised absence of

headache.

Patient was relieved of dizziness and was injury free throughout period of

hospitalization.

Again on the 28/09/2018 at 11am, patient complain of dizziness. A nursing diagnosis of high

risk for injury related to dizziness was formulated. An objective was set to ensure patient was

free from injury till she was discharged. Nursing orders carried out were; Patient was

reassured that she will be relieved of the dizziness with good health care been rendered. Side

rails were elevated to prevent fall and all source of injury was removed i.e. sharps e.g. free

needles. Complete bed rest was ensure and patient was assisted in self-care activities i.e.

bathing, mouth care. Prescribed antihypertensive and sedatives were served e.g. tablet

diazepam 10mg and tablet Nifedipine 20mg and side effects of drugs was monitored.

On the day of (03/10/2018), at 8am Mrs. E.A was assessed to evaluate goals set to ensure

patient was free from injury due to dizziness. Goal was fully met as patient was free from

injury.

Mrs. E.A was relieved of anxiety within 24 hours

Moreover at 11:15am of the day of admission, patient was observed to be anxious. An

objective was set to help relieve patient of anxiety within 24hours. In order to achieve the

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goal set, Patient was reassured that, with their cooperation and compliance to treatment

regimen, the condition can be controlled. Patient was educated on the need for hospitalization

and nursing procedures that were performed on the patient were explained to her to gain her

cooperation .Patient was then encouraged to ask questions about hypertension. Simple and

straight forward answers were provided to her questions promptly and tactfully. Other

patients recovering from the same condition were introduced to her. Physiological response

such as palpitations, headache, restlessness etc. was observed for the degree of fear and

anxiety patient was facing.

On the 29/09/2018, at 11:15am, the objective set to ensure patient was relieved of anxiety

was evaluated. Goal was fully met as patient verbalised that she was no more anxious about

the prognosis of the disease.

Mrs. E.A was relieved of palpitations throughout period of admission

Moreover, on the day on admission at 11:15am, Mrs. E.A complain of palpitations. Alteration

in body comfort related to palpitations was formulated as a nursing diagnosis. An objective

was set to ensure patient was relived of palpitations throughout the period of admission.

Nursing interventions carried out were; patient was reassured that palpitations will stop with

good nursing care. Calm restful environment was ensured. Number and length of visitors was

limited. Activity was restricted during crises as patient was encouraged to rest and relax. And

also enough bed rest ensured. Patient was taught relaxation techniques. Vital signs were

checked and recorded especially the value of pulse was noted and charted appropriately.

Prescribed antihypertensive, sedatives etc. served and side effects monitored.

On the day of discharge, (03/10/2018) at 8am, Mrs. E.A was assessed to evaluate goals set to

ensure patient was free from palpitations. Goal was fully met as patient verbalised absence of

palpitations.

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Mrs. E.A regained her normal sleep pattern within 48 hours

On the 29/09/2018, at 8am during interaction with patient, it was identified that patient had

insomnia. A nursing diagnosis of sleep pattern disturbance (insomnia) related to change of

environment (hospitalization). An objective was set to help patient sleep well within 48

hours. Interventions carried out were; Patient was reassured that with good nursing care she

will be able to sleep and bed was laid devoid of creases, cramps and patient was made

comfortable in bed. Noise free environment provided by switching off nearby televisions and

restricting visitors. Proper ventilation provided by opening nearby windows and switching on

fans. Warm bath given and warm drinks served eg. Warm milo drink. Prescribed drugs or

medication served e.g. tablet paracetamol 1g, tablet diazepam, tablet amlodipine and the side

effects were monitored.

On the 01/10/2018, at 8am, goal set to ensure patient was able to sleep well was evaluated.

Goal was fully met as Mrs. E.A verbalised that she slept uninterrupted in the night and could

now sleep at least 1 hour in the afternoon.

Mrs. E.A had adequate knowledge hypertension within 24 hours

On the 30/09/2018, at 9am during interaction with patient, it was realised patient had limited

knowledge on her disease condition. Nursing diagnosis of knowledge deficit related to lack of

inadequate information on causes, signs and symptoms and prevention of disease condition. An

objective was set to ensure patient had adequate knowledge on the disease condition within 24

hours. Nursing orders carried out included Patient and family were reassured that detailed

information on hypertension will be given for better understanding. Time was scheduled with

patient and relatives to educate them on hypertension. Patient was then made comfortable by

lying in bed whiles relatives and the nurse sat by bedside. Patient and family knowledge on

hypertension was assessed. Accurate information on the predisposing causes, signs and

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symptoms, prevention, drug management and lifestyle modification were provided to correct

misconceptions. Questions were invited and tactfully answered. Finally, pamphlets on

hypertension were given to patient to ensure she is able to refer from it even when she is

discharged. On the 01/10/2018 at 8am, Also, patient assessed to evaluate the goal set to ensure

patient had adequate knowledge on disease condition. Goal was also fully met as Mrs. E.A was

able to answer questions on the causes, signs, symptoms and treatment plan for hypertension.

5.2 Amendment of Nursing Care Plan

All the objectives set to help Mrs. E.A out of her health problems were met within the

stipulated times therefore there was no amendment to be done to the care plan originally

drawn. Due to the maximum cooperation by Mrs. E.A and her family, all objectives set

were fully met. Therefore no care plan was amended

5.3 Termination 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 patient and family from the day

of admission.

The termination of Mrs. E.A care started on the first day of interaction with her and her

family on 28/09/2018. To avoid separation anxiety, they were told that, our relationship was a

therapeutic one and would last for a reasonable period. They were also told that I would not

be able to stay on the ward for 24 hours with them, hence the need for their co-operation with

other nurses and paramedical staff on the ward. They were therefore not surprised when they

were finally told about the termination of the care and my relationship with them on the

14/10/2018. On this day, I visited my patient and family in her house with a public health

81
nurse from the public health unit of the Ghana Health service for continuity of care. I

promised to visit them anytime I had the opportunity. I thanked them sincerely for their co-

operation. They in turn thanked me for the care rendered. Mrs. E.A was successfully handed

over to Mrs. Fallilatu and care was officially terminated.

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CHAPTER SIX

SUMMARY AND CONCLUSION

6.0 Introduction

This is the last step of the patient/family care study which entails the student’s personal

appreciation of the therapeutic relationship with the patient as well as the use of the nursing

process.

6.1 Summary

Mrs. E.A, a 33 year old a hair dresser from Tom in Nkoranza was admitted to the female's

ward of the St. Theresa’s Hospital (Nkoranza) on 28/09/2018. Patient was diagnosed of

Hypertension and the various laboratory investigations and clinical features helped to confirm

the diagnosis. On observation and examination, she was conscious but complained of

headache, palpitations and dizziness. The following investigation/test were ordered and

carried out on Mrs. E.A.; blood for malaria parasites, blood for full blood count, urine for

urinalysis and blood for BUE and creatinine.

Patient was managed on the following medications throughout admission;

Hydralazine hydrochloride (intra venous) 10mg stat

Tab Losartan 100mg daily for 30 days

Tablet Methyldopa 1g twice daily for 30 days

Tablet Bendroflumethiazide 5mg daily x 30

Tablet diazepam 10mg nocte for 5 days

Tablet Aspirin 75mg daily for 14 days

Tablet Paracetamol 1g tds for 5 days

Tablet Amlodipine 10mg daily for 30 days.

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Throughout admission, six problems were identified and care plan drawn to solve it. They

were headache, dizziness, anxiety, palpitations, insomnia and knowledge deficit.

Patient and family were educated on the causes of the disease as through increased vascular

resistance and increased cardiac output. The predisposing factors were also unfolded to him

such as stress, lack of exercises and high sodium intake

The signs and symptoms as exhibited by patient were mentioned to him as well the

prevention of the disease (hypertension) through nutritious diet of low sodium, fats and

cholesterol.

Patient was also assisted in maintaining his personal hygiene (care of the mouth, hair, toe and

fingers nails and skin). Rest and sleep, elimination, nutrition, clothing and exercises were also

ensured and patient’s husband was encouraged to continue care at home after discharge. He

was encouraged to assist with the home chores to prevent excessive stress when patient was

discharged.

She responded to the treatment quickly and condition improved. Mrs. E.A. was nursed for a

total of 6 days from 28/09/2018 to 03/10/2018 when she was discharged.

On the 10/10/2018, patient reported for review as scheduled and Mrs. E.A.’s condition had

improved.

Follow up visits were made to assess the home situation, to find out the actual and potential

problems that contributed to the patient’s illness and also to find ways of solving them, find

out if patient was able to observe the drug regimen and to know her response to treatment

after leaving the hospital.

Moreover, to find out if patient and family is carrying out the advice and all education given

to improve patient and family’s health and standard of living.

Patient care was terminated during the third home visit when it was realized that patient was

fully covered and was managing well with her condition. Mrs. E.A and her family were

84
handed over to the community health nurse for continuity of care. Care was terminated on the

14/10/2018.

6.2 Conclusion

The care rendered to Mrs. E.A. and her family has really helped me to gain a great

knowledge on hypertension after nursing him. It has also offered me a great opportunity to

know how to nurse individuals with hypertension. It has also helped me to practice my skills

acquired in the classroom theoretically.

To the patient and family, this care study has enabled me to render an individualized care to

them and has also help them to know the need to report to the hospital immediately they have

any changes in the normal functioning of any part of their body. It has deepened my

relationship with patients, families and the people in that community as a whole.

To the hospital, I recommend that all patients admitted to the hospital are to be nursed using

the nursing care plan.

And to my institution, a copy of this care study will be kept in the college library to be used

by the college community.

It is my recommendation that all students are given the opportunity to embark on the

patient/family care study to implement the nursing process in order to render individualized

comprehensive care to patients and families. In brief, I really enjoyed every bit of writing this

script despite the challenges encountered.

As this care study is kept in the college library, it will be used for research purposes and

future reference for student.

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APPENDIX
Table 8: Vital signs chart for Mrs. E.A
Date Time Blood pressure Pulse Temperature Respiration
mmHg bpm oc cpm
28/09/18 11am 190/110 84 36.9 21
2pm 180/90 120 35.7 28
6pm 170/90 90 36.3 25
10pm 160/90 95 36.5 23
29/09/2018 6am 130/90 88 36.7 20
10am 140/90 85 35.9 21
2pm 150/100 90 36.0 22
6pm 140/90 85 36.1 24
10pm 150/80 82 35.9 22
30/09/2018 6am 150/90 87 36.7 24
10pm 140/80 80 36.1 21
2pm 160/100 82 35.9 22
6pm 140/80 79 36.0 18
10pm 130/80 90 35.9 23
01/10/2018 6am 150/90 78 35.7 20
10pm 130/80 78 36.7 22
2pm 120/90 85 36 21
6pm 130/80 79 35.9 22
10pm 140/70 84 36.9 24
02/10/18 6am 120/90 80 36.3 20
10am 130/70 79 36.8 23
2pm 110/70 82 36.0 21
6pm 120/80 78 35.9 24
10pm 130/75 82 35.7 22
03/10/18 6am 120/90 80 36.3 20
10/10/18 9:15am 130/70 76 36.7 76

86
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Kumar, P. J., and Clark, M. L., (2011).Kumar and Clark clinical medicine, Edinburgh;
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Marilyn E., Mary F.M., & Alice C.M., (2012), Nursing care plans guidelines for

individualizing patient care across the life span, 8th edition, F.A Davis

Company. Philadelphia

Ministry of health /Ghana health service.(2010).standard treatment guidelines 10th edition,

Accra, Ghana.

Waugh, A. and Grant, A. (2010).Ross and Wilson Anatomy and Physiology in Health and

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Others

www.nursesnanda.com accessed on the 3rd of October, 2018

Patient folder number : 004775/14 ST. Theresah’s Hospital, Nkoranza

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