CHAPTER TWO: COMPARISON OF CLINICAL FEATURES OF PATIENT AND THAT OF LITERATURE

By | July 11, 2021

VALIDATION OF DATA

The client’s personal data was provided by herself and her mother. The data collected was confirmed by her father on his arrival. The clinical features observed in the client were also compared to those in textbooks as well as laboratory investigations and the direct relation indicated that the client is suffering from TYPHOID FEVER which made her develop complications called TYPHOID PERFORATION.

The above comparison enabled me to conclude that, the data collected is valid and free of errors.

CAUSES OF CLIENT’S DISEASE

 

Regarding etiological factors of typhoid fever, indicated in the literature review and the data gathered from my interaction with the client and her relatives, Akosua’s condition was caused by unhygienic cooking and eating habit.

Considering her sanitation and where she buys food from, and also due to delay in diagnosis and treatment which lead to intestinal perforation, a complicated form.

 

COMPARISON OF CLINICAL FEATURES OF PATIENT AND THAT OF LITERATURE

 

LITERATURE FEATURES AKOSUA’S CLINICAL FEATURES
There is fever

 

There is anorexia

 

There is abdominal pain

 

There is abdominal tenderness

 

Spots or rashes on the trunk of the body

 

Headache may be present

 

There may be joint pain

 

There may be malaise

 

Prostration may be present

 

There is constipation

 

There is diarrhea

 

Dysuria may be present

 

There may be abdominal distention

 

There may be anemia

The client had pyrexia of 38.0 degrees Celsius.

 

The client did not complain of anorexia.

 

The client complained of severe abdominal pain.

 

Abdominal tenderness present

 

No rash was present

 

The client complained of a headache

 

Joint pain was experienced by the patient

 

The client experienced general malaise

 

The client did not experience prostration

 

She did not experience constipation.

 

Client experienced diarrhea

 

Dysuria was not present

 

Abdominal distention present

 

Mild anemia was present.

 

CHAPTER TWO

 

ANALYSIS OF DATA

The analysis is the second phase of the nursing process and it involves the separation of information collected from the client into constituent parts, to compare them with standards, formulates the nursing diagnosis, and intervenes accordingly.

This chapter comprises of

Comparison of data with standard

The patient/family strength

Health problems

Nursing diagnosis

CHAPTER TWO: COMPARISON OF CLINICAL FEATURES OF PATIENT AND THAT OF LITERATURE

PATIENT’S/ FAMILY STRENGTHS

On admission, my client was conscious and followed nursing instructions. She had her mother at her side always and even though the family is not rich, they were able to buy any drug which was not covered by the National Health Insurance.

Family members used to visit her from time to time on the ward.                                                    

As her condition improved, Akosua was able to maintain her personal hygiene without assistance; she could eat and groom herself.

These activities by the client and the family helped in her wellbeing and also contributed to her speedy recovery.

 

HEALTH PROBLEMS IDENTIFIED

A health problem is any stressful activity that can cause an adverse reaction to client health and therefore needs effective management.

The following health problems were identified during the period of admission of my client, Akosua Naa.

 

PRE-OPERATIVES:

The client experienced pyrexia and headache.

The client had severe abdominal pain and distension.

The client and family were anxious.

POST-OPERATIVES:

The client had pain at the incisional site.

The client could perform her personal hygiene.

The client could not breathe well.

The client was prone to infection.

The client had insomnia.

The client had a loss of appetite.

The client had inadequate knowledge about the disease condition.

NURSING DIAGNOSIS

 

Upon observations and complaints by the client, the following nursing diagnoses were reached;

 

PRE-OPERATIVES

  1. Alteration in body temperature (38.00C) related to typhoid fever with perforation.
  2. Alteration in comfort (abdominal pain) related to abdominal distension.
  3. Anxiety-related to impending surgery (laparotomy) secondary to the disease condition.

 

POST-OPERATIVES

  1. Alteration in comfort (incisional wound pain) related to surgical intervention.
  2. Total self deficit related to laparotomy.
  3. Breathing pattern disturbances related to typhoid perforation.
  4. Potential for wound infection related to incisional wound secondary to surgery (laparotomy).
  5. Sleeping pattern disturbance related to change of environment.
  6. Altered nutrition is less than body requirement related to restriction of food by mouth.
  7. Knowledge deficit related to the cause and management of typhoid fever.

CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

 

Planning is the third phase of the nursing process and it involves the setting of goals, determination of priorities and planning a care to prevent or eliminate a client’s health problems, and identifying nursing interventions to meet the set goals.

The client and the family members must be involved in the nursing care plan.

 

GOALS AND OBJECTIVES

  1. The client will maintain a normal body temperature of 36.2oC-37.oC within 3 hours as evidenced by the nurse taking her temperature and observing that it has dropped to the normal range.

 

  1. The client will be relieved of abdominal pain within 2 days as evidenced by;
  2. a) Nurse observing that client does not have abdominal distension.
  3. b) Client verbalizing relief of pain and being cheerful.

 

  1. Client and family will be relieved from anxiety within 24hrs as evidenced by client and mother having cheerful facial expressions and being cooperative.

 

  1. The client will be relieved of post-operative pain within 1 hour as evidenced by the client verbalizing that the pain has subsided.

 

  1. The client will be able to maintain her personal hygiene within 4 days post-operatively with little or no assistance as evidenced by
  2. a) Nurse observing the client being able to maintain her personal hygiene with minimum assistance.
  3. b) Client verbalizing that she can maintain her personal hygiene by herself.

 

  1. The client will have a normal breathing pattern within 4 hours as evidenced by
  2. a) Nurse checking respiratory rate and falling within normal range
  3. b) Client verbalizing that she can breathe normally.

 

  1. The client’s wound will be free from infection and wound heal by the first intention within 7 days post-operatively as evidenced by nurse observation that client’s wound appearing dry and clean without infection.

8. Clients will have a normal sleeping pattern throughout the period of hospitalization as evidenced by; client sleeping at least 3 hours during the day and 6 – 8 hours in the night.

9.Client nutritional status will be maintained within 5days post-operatively as evidenced by

the nurse observing the client not malnourished and client being able to take and tolerate more than half of the food served.

  1. The client will have insight into her disease condition before discharge as evidenced by the client answering questions on her condition correctly.

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