ASSESSMENT OF PATIENT/FAMILY
Assessment involves the systematic collection of data about the client’s health status, which can be obtained from the client’s relatives, friends, and the client`s folder. The data gathered is used to make nursing diagnoses and plan care to solve client problems. The data was collected through observations, investigations such as laboratory information, x-ray findings and results, and literature from books.
Miss. Akosua Naa, a 24-year-old lady is born to Mr. KwadwoSule and Madam AfiaNaa, all Ghanaians. Akosua is tall, fair in complexion, and weighs 55kg. She has no tribal mark on the face and is the third born in the family of six children of which one is a male and five are females. She was born in Nasole at Wasa in the Western region of Ghana, where she comes from. Akosua lives in Ejura with two of her elder siblings and the parents live in Oku, a suburb of Ejura. She left the parents to live in Ejura to learn how to sew. She is a Christian and worships with the Catholic Church. Akosua speaks Dagaate and Twi but never attended school. The next of kin is Madam AfiaNaa, her mother. She was admitted to KomfoAnokye Teaching Hospital on the 4th of January 2010.
FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY
FAMILY’S MEDICAL HISTORY
A family is a group of people, related by blood, marriage, or adoption, living together and interacting with each other. There are two types of families, namely Nuclear families, comprising of mother, father, and children. The second type of family called the Extended family also comprises the nuclear family and the other relatives living together in a household or apart.
Akosua Naa belongs to the extended family type, and to regain her health to normal, her family’s medical and socio-economic status is taken into consideration.
According to my client, Akosua, there are no known hereditary disease conditions like Hypertension, Diabetes Mellitus, Sickle cell disease, Asthma, or Mental disorders in the family. She also added that there are no known chronic infections such as Leprosy, and Tuberculosis in the family, however, she admitted that an Aunty from her paternal side had epilepsy and died of it. Her sister next to her had jaundice but was treated and completely recovered from the illness.
Minor ailments like Fever, Headache, Abdominal pain, Malaria, and Common cold in the family are usually treated with herbal preparations and over-the-counter drugs. The mother confirmed the above information received.
Miss Akosua Naa is an apprentice seamstress, who does no other work aside from the seam stressing but depends on her parents for financial assistance. She goes to her parents from time to time to collect money and some foodstuff. The father, Mr. Sule is a Cocoa farmer and the breadwinner of the family, and the mother is a cereal crop farmer who assists the father to care for the children. Her elder brother sometimes also assists her financially.
Concerning the standard of living of Akosua and her family, it can be said that they are below the average socio-economic background by Ghanaian standard. Due to this, the patient and the mother always resist any issue involving money.
PATIENT’S DEVELOPMENTAL HISTORY
Development is the process whereby one changes from a stage of maturity to another. Development takes place from the very day of conception till the death of an individual. These stages include physical, psychological, psychosexual, cognitive, and emotional development.
According to Madam AfiaNaa, the client’s mother, she had a normal pregnancy and deliver at term spontaneously per vagina. She delivers at home with little assistance from traditional birth attendants and has no associated pregnancy, labor, and puerperium problems. She did not attend the antenatal clinic but for immunization, she made sure all her children received them accordingly.
Akosua Naa does not know her exact date of birth but presumed she is about 24 years. She did not attend school. She had her menarche at 15 years and 4 days is her normal menstrual flow. Akosua is not married yet.
Ms. Akosua Naa is a Catholic, who goes to church every Sunday. Her favorite diet is Fufu and palm nut soup. She also likes taking in soft drinks like Fanta. She usually baths twice a day with soap, sponge, and cold water and brushes her teeth once a day with a toothbrush and paste. She empties her bowels usually once a day. Her hobbies are cooking and charting with friends. She is an introvert but goes on well with friends. Akosua sleeps as early as 8 p.m and wakes up around 5:00 am. when she wakes up in the morning; she prays to God and begins her daily activities. She sweeps the house and fetches water; afterward, she prepares breakfast for herself and other siblings or sometimes buys food from outside. She then goes to work.
According to Akosua, she does not usually eat in the afternoon except for water and sometimes snacks like ice kenkey and bread. Around 4:30 p.m, she closes from work and goes home to prepare the evening meals or buys food outside.
All these assertions by the client were confirmed by her elder sister, Adwoa.
PATIENT’S PAST MEDICAL HISTORY
Ms. Akosua Naa has no previous major illness or admission into the hospital. She has not engaged herself in any serious accident or injury before. However, she occasionally has headaches and stomach aches of which she takes pain relievers, for example, buying paracetamol tablets from nearby drug stores.
PRESENT MEDICAL HISTORY
Miss Akosua Naa decided to spend the Christmas holidays with her parents at Oku, a village inside Ejura. All was well until the 1st of January, 2010 when she started experiencing headaches; she took paracetamol and decided to rest for a while. Upon waking up, the headache had subsided but had severe abdominal pain. Her mother made some herbal preparations for her but her pain aggravated and she was taken to Oku Health Center and was admitted for two days where she was given some infusions. Later she was transferred to Ejura Hospital. Upon assessment, Ejura Hospital also transferred her to Mampong Government Hospital. Series of investigations like a negative pregnancy test, HB count, and WBC count were performed on her. She was Haemo-transfused one pint of Whole blood because she was anemic.
Mampong Government Hospital referred her to KomfoAnokye Hospital for further treatment on the same day, they admitted her.
On the 4th of January, 2010 around 8:40 pm, the client and the mother reported at the accident and emergency department as a referred case from Mampong Government Hospital with generalized peritonitis. She was given some palliative treatment and some investigations were done.