CHAPTER ONE
ASSESSMENT OF PATIENT AND FAMILY
Assessment is the first phase in the nursing process. It involves systematic collection of
information from the patient, his relatives, his folder, healthcare professionals and health related
books. It also helps in identification of client’s problem as well as the family to draw a care plan
for their care.
This is done through observations and interviews, clinical investigations such as blood test, are
carried out to help in identifying patient and family problems which can help patient to lead a
normal independent life.
1.1 PATIENT’S PARTICULARS
E.G. who is a subject of the care study is 9 years old, born to Mr Galm ma, and Mrs. M. Galma
on the 4th September 2008. He is the only son of his parent. E.G is a Ghanaian and hails from
Amoma District in the Brong Ahafo Region. He is a Dagao by tribe, he speaks Dagaate, English
and Twi. He is about 52 centimetres tall and weighs 29.5kg. He comes from Jirapa but currently
stays at Amoma.He lives with his parents in house number (TY0415) plot 15. He is fair in
complexion with silky hair. He is a Christian and belongs to the Roman Catholic Church of
Ghana at Amoma and attends church with parent and other relatives. E. G is a student and attend
R/C school at Amoma.He is in class 4. His next of kin is Mrs. M.G, his mother.
1.2 FAMILY’S MEDICAL HISTORY
For the family’s medical history, E. G’s mother could not tell of their exact status. She said, they
don’t have any hereditary conditions such as Psychosis, Hypertension, Diabetes Mellitus,
Asthma, Epilepsy, Sickle Cell Disease in their family. She went on to say that none of the family
members had suffered any impending or chronic disease. They however suffer minor ailment
such as headaches, fever, common cold and cough which they mostly report at the hospital for
treatment on out-patient basis and sometimes resorted to traditional medicines and prayers.
According to E. G’s mother, she has not recognise any allergies of E.G.
1.3 FAMILY’S SOCIO-ECONOMIC HISTORY
According to E.G’s mother, their main financial sources come from their petty trading which is
enough to pay their bills. The daily needs of E.G depend on the father who earns One thousand
and twenty Ghana Cedis (Gh 1, 20.00) every 6 months, which mostly depends on the season.
Despite the family members been in the middle income class, they are able to provide the needs
,of E.G to ensure his survival. Mr.F. G, his father is a farmer and support very well according to
his mother. Mrs. MG. His mother is a food vender and according to her earns about 50 cedi on a
good day.
1.4 PATIENT DEVELOPMENTAL HISTORY
According to Baillieres nursing dictionary, twenty fourth edition, Development is the process of
growth and differentiation.is the development of intelligence, conscious thought, and problem
solving ability that begins in infancy.
Growth is also the progressive development of a living think, especially the process by which the
body reaches its point of complete physical development. Maturation is the unfolding of natural
potentials.
According to E. G’s mother, she experienced normal pregnancy for a period of nine months and
did not experience any disease during that period. She attended antenatal clinic regularly at
Amoma; Wame Maternity home and had spontaneous vaginal delivery at Amoma Clinic. He was
immunised against all the childhood disease that are BCG, polio, diphtheria, pertusis, tetanus,
Hepatitis B, Haemophilia influenza Type B, Measles and yellow fever.
Mother stated that during Antenatal care visit she was thought about exclusive breastfeeding for
6 months but E.G was breastfed for 3 months stating that there was inadequate breast milk for
the child. She started introducing supplementary feeds such as porridge and milk. According to
mother, E.G had neck control at age 3-4 months.
At age of 6 -9months his weight doubles, she said he begins passive rolling movement by which
he carried up himself and he also
grasp and release an object at the age of 7 months, E.G sits without support and begins to crawl.
At the age of 8 months he begins to stand up and stay up by grasping for support and develops by
putting things in his mouth. At the age of nine months E.G begins to feed himself with bread,
biscuit or can hold his own feeding bottle. He also begins to verbalise all vowels and most
consonants but cannot speak very well. He can put words together like “mama” and “dada”, he
can also wave goodbye to his parents.
At the age of ten months his weight triple and birth length increases about 50%.
He was weaned at one and half years of age and was able to walk. He was able to run around,
and capable of bowel and bladder control at two years and could play with other children. At age
3-4years, he could stand on one leg, jump up and down, draws a circle and a cross. E.G started
school when he was two years, at Roman crèche at Amoma, at ag 4-5years, he prefars to play
with other children he is currently inthat same school and in class four (4).
According to Eric Erikson's psychosocial theory, with ages between 6 and 12years experiences
industry versus inferiority of which my patient falls within, explains that; children begin to learn
skills, values by society, and success or failure can affect a child's feeling of adequacy. Children
learn a sense of industry if they win praise for productive activities. Example reading, studying
etc. If a child's efforts are regarded as inadequate, feeling of inferiority results. According to E.
,G’s mother, he is always praise for any academic achievement. And with Erikson's development
theory, E.G had a normal growth spurt.
PATIENT’S LIFE STYLE / HOBBIES
According to Mrs.M. G, E. G’s mother, he wakes up at 6:00am on school days; he empties his
bowel, brushes his teeth with tooth brush and toothpaste, takes his bath, eats his breakfast, wear
his uniform and then goes to school with friends who stays around his house. E.G said he likes
playing football at school with his peers during break hours.
Mrs. M.G said E.G usually returns from school around 2:30pm. He eats food which she has
prepared for him and sometimes buys food from the food vendors as well. He removes his cloth
and goes outside to play with his friends. By 6:30pm he takes his bath and solves his assignment.
After which, he watches television for a while and finally goes to bed at 9:30pm.
E.G said during weekends he goes to classes, then after closing he spends the rest of the day
either with his mother at where she sells food or stays in the house and play with friends. E . G’s
mother said during vacation, he usually attends vacation classes. After closing, he goes out and
play football with his peers. He sometimes helps his mother at where she sells the food.
According to his mother he is very brilliant and he is always admired by the tutors. He
sometimes comes home with different kinds of gift. His mother said, she has not recognized any
allergic substance on E.G. He likes playing football. E.G dislikes insulting and lies. The food he
likes best is rice and tomato stew. E.G likes playing with his peers. Personally, E.G is the type I
really like, because he is calm and gentle, fast in understanding and respectful.
PAST MEDICAL HISTORY
According to E. G’s mother, he has never been hospitalized. He occasionally experienced minor
ailment such as fever or cold which they treat using drugs from a pharmaceutical shop.
According to E. G’s mother, he was apparently well until 3 days ago when he developed fever.
The mother then took him to the Amoma clinic where he was given some oral medications. But
symptoms still persisted, which made them report to the Holy Family Hospital- Techiman,
through which he was admitted at the paediatric ward. According to his mother, they do not
usually visit the hospital. He has not been admitted before.
PRESENT MEDICAL HISTORY
On the 21st of December, Mrs. M.G reported E.G to the Holy Family Hospital and was seen by
Dr. Desmond in the consulting room 2. E. G’s mother complains of High body temperature,
, changes in eye colour, constipation, anorexia, and vomiting. The doctor admitted E.G to the
paediatric ward for management and monitoring.
ADMISSION OF PATIENT
Brother E.G was admitted to the paediatric ward on the 21st December 2017, at 11:00am through
the out-patient department (OPD). He was given a provisional diagnosis of malaria.
He came to the ward with the mother and an accompanied nurse. E.G was in a conscious state.
E.G and his mother were welcome into the ward and were offered seats at the nurses’ station. His
name was taken and his particulars were then entered into the admission and discharge book and
on the daily ward state. Particulars such as name, sex, home address, hometown religion and next
of kin were taken from the mother and recorded in his folder. A simple unoccupied bed was
provided for E.G.
Vital signs checked and recorded as follows;
Temperature – 38.5ᵒC
Pulse - 136 bpm
Respiration - 34cpm
On admission, the mother complained that, E.G is having High body temperature,
vomiting, anorexia, constipation, change in eye colour. Mother and child was reassured that
necessary nursing and medical intervention would be put in place to restore him to normal
health.
His weight was also checked and recorded as 25.9kg. Physical examination on patient was done
from head to toe and child’s eye appear to be yellowish in colour.
ASSESSMENT OF PATIENT AND FAMILY
Assessment is the first phase in the nursing process. It involves systematic collection of
information from the patient, his relatives, his folder, healthcare professionals and health related
books. It also helps in identification of client’s problem as well as the family to draw a care plan
for their care.
This is done through observations and interviews, clinical investigations such as blood test, are
carried out to help in identifying patient and family problems which can help patient to lead a
normal independent life.
1.1 PATIENT’S PARTICULARS
E.G. who is a subject of the care study is 9 years old, born to Mr Galm ma, and Mrs. M. Galma
on the 4th September 2008. He is the only son of his parent. E.G is a Ghanaian and hails from
Amoma District in the Brong Ahafo Region. He is a Dagao by tribe, he speaks Dagaate, English
and Twi. He is about 52 centimetres tall and weighs 29.5kg. He comes from Jirapa but currently
stays at Amoma.He lives with his parents in house number (TY0415) plot 15. He is fair in
complexion with silky hair. He is a Christian and belongs to the Roman Catholic Church of
Ghana at Amoma and attends church with parent and other relatives. E. G is a student and attend
R/C school at Amoma.He is in class 4. His next of kin is Mrs. M.G, his mother.
1.2 FAMILY’S MEDICAL HISTORY
For the family’s medical history, E. G’s mother could not tell of their exact status. She said, they
don’t have any hereditary conditions such as Psychosis, Hypertension, Diabetes Mellitus,
Asthma, Epilepsy, Sickle Cell Disease in their family. She went on to say that none of the family
members had suffered any impending or chronic disease. They however suffer minor ailment
such as headaches, fever, common cold and cough which they mostly report at the hospital for
treatment on out-patient basis and sometimes resorted to traditional medicines and prayers.
According to E. G’s mother, she has not recognise any allergies of E.G.
1.3 FAMILY’S SOCIO-ECONOMIC HISTORY
According to E.G’s mother, their main financial sources come from their petty trading which is
enough to pay their bills. The daily needs of E.G depend on the father who earns One thousand
and twenty Ghana Cedis (Gh 1, 20.00) every 6 months, which mostly depends on the season.
Despite the family members been in the middle income class, they are able to provide the needs
,of E.G to ensure his survival. Mr.F. G, his father is a farmer and support very well according to
his mother. Mrs. MG. His mother is a food vender and according to her earns about 50 cedi on a
good day.
1.4 PATIENT DEVELOPMENTAL HISTORY
According to Baillieres nursing dictionary, twenty fourth edition, Development is the process of
growth and differentiation.is the development of intelligence, conscious thought, and problem
solving ability that begins in infancy.
Growth is also the progressive development of a living think, especially the process by which the
body reaches its point of complete physical development. Maturation is the unfolding of natural
potentials.
According to E. G’s mother, she experienced normal pregnancy for a period of nine months and
did not experience any disease during that period. She attended antenatal clinic regularly at
Amoma; Wame Maternity home and had spontaneous vaginal delivery at Amoma Clinic. He was
immunised against all the childhood disease that are BCG, polio, diphtheria, pertusis, tetanus,
Hepatitis B, Haemophilia influenza Type B, Measles and yellow fever.
Mother stated that during Antenatal care visit she was thought about exclusive breastfeeding for
6 months but E.G was breastfed for 3 months stating that there was inadequate breast milk for
the child. She started introducing supplementary feeds such as porridge and milk. According to
mother, E.G had neck control at age 3-4 months.
At age of 6 -9months his weight doubles, she said he begins passive rolling movement by which
he carried up himself and he also
grasp and release an object at the age of 7 months, E.G sits without support and begins to crawl.
At the age of 8 months he begins to stand up and stay up by grasping for support and develops by
putting things in his mouth. At the age of nine months E.G begins to feed himself with bread,
biscuit or can hold his own feeding bottle. He also begins to verbalise all vowels and most
consonants but cannot speak very well. He can put words together like “mama” and “dada”, he
can also wave goodbye to his parents.
At the age of ten months his weight triple and birth length increases about 50%.
He was weaned at one and half years of age and was able to walk. He was able to run around,
and capable of bowel and bladder control at two years and could play with other children. At age
3-4years, he could stand on one leg, jump up and down, draws a circle and a cross. E.G started
school when he was two years, at Roman crèche at Amoma, at ag 4-5years, he prefars to play
with other children he is currently inthat same school and in class four (4).
According to Eric Erikson's psychosocial theory, with ages between 6 and 12years experiences
industry versus inferiority of which my patient falls within, explains that; children begin to learn
skills, values by society, and success or failure can affect a child's feeling of adequacy. Children
learn a sense of industry if they win praise for productive activities. Example reading, studying
etc. If a child's efforts are regarded as inadequate, feeling of inferiority results. According to E.
,G’s mother, he is always praise for any academic achievement. And with Erikson's development
theory, E.G had a normal growth spurt.
PATIENT’S LIFE STYLE / HOBBIES
According to Mrs.M. G, E. G’s mother, he wakes up at 6:00am on school days; he empties his
bowel, brushes his teeth with tooth brush and toothpaste, takes his bath, eats his breakfast, wear
his uniform and then goes to school with friends who stays around his house. E.G said he likes
playing football at school with his peers during break hours.
Mrs. M.G said E.G usually returns from school around 2:30pm. He eats food which she has
prepared for him and sometimes buys food from the food vendors as well. He removes his cloth
and goes outside to play with his friends. By 6:30pm he takes his bath and solves his assignment.
After which, he watches television for a while and finally goes to bed at 9:30pm.
E.G said during weekends he goes to classes, then after closing he spends the rest of the day
either with his mother at where she sells food or stays in the house and play with friends. E . G’s
mother said during vacation, he usually attends vacation classes. After closing, he goes out and
play football with his peers. He sometimes helps his mother at where she sells the food.
According to his mother he is very brilliant and he is always admired by the tutors. He
sometimes comes home with different kinds of gift. His mother said, she has not recognized any
allergic substance on E.G. He likes playing football. E.G dislikes insulting and lies. The food he
likes best is rice and tomato stew. E.G likes playing with his peers. Personally, E.G is the type I
really like, because he is calm and gentle, fast in understanding and respectful.
PAST MEDICAL HISTORY
According to E. G’s mother, he has never been hospitalized. He occasionally experienced minor
ailment such as fever or cold which they treat using drugs from a pharmaceutical shop.
According to E. G’s mother, he was apparently well until 3 days ago when he developed fever.
The mother then took him to the Amoma clinic where he was given some oral medications. But
symptoms still persisted, which made them report to the Holy Family Hospital- Techiman,
through which he was admitted at the paediatric ward. According to his mother, they do not
usually visit the hospital. He has not been admitted before.
PRESENT MEDICAL HISTORY
On the 21st of December, Mrs. M.G reported E.G to the Holy Family Hospital and was seen by
Dr. Desmond in the consulting room 2. E. G’s mother complains of High body temperature,
, changes in eye colour, constipation, anorexia, and vomiting. The doctor admitted E.G to the
paediatric ward for management and monitoring.
ADMISSION OF PATIENT
Brother E.G was admitted to the paediatric ward on the 21st December 2017, at 11:00am through
the out-patient department (OPD). He was given a provisional diagnosis of malaria.
He came to the ward with the mother and an accompanied nurse. E.G was in a conscious state.
E.G and his mother were welcome into the ward and were offered seats at the nurses’ station. His
name was taken and his particulars were then entered into the admission and discharge book and
on the daily ward state. Particulars such as name, sex, home address, hometown religion and next
of kin were taken from the mother and recorded in his folder. A simple unoccupied bed was
provided for E.G.
Vital signs checked and recorded as follows;
Temperature – 38.5ᵒC
Pulse - 136 bpm
Respiration - 34cpm
On admission, the mother complained that, E.G is having High body temperature,
vomiting, anorexia, constipation, change in eye colour. Mother and child was reassured that
necessary nursing and medical intervention would be put in place to restore him to normal
health.
His weight was also checked and recorded as 25.9kg. Physical examination on patient was done
from head to toe and child’s eye appear to be yellowish in colour.
