CHAPTER THREE
A. NURSING ASSESSMENT
PERSONAL DATA
Name - Mr. N A
Age - 70 years old
Date of Birth - 23rd March 1955
Sex - Male
Tribe - Eggon
Marital Status - Married
Religion - Christian
LGA - Lafia
State of Origin - Nasarawa
Nationality - Nigerian
Home Address - Fefe Ruwa, Asakio
Occupation - Retired Civil Servant
Next of Kin - Cornelius Ankpava
Address of Next of Kin - Fefe Ruwa, Asakio
Date of Admission - 23rd March 2025
Ward - Male Surgical Ward
Diagnosis - Intestinal Obstruction
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B. HISTORY TAKING
Family and Social History
Mr. A.N is a teacher, who is married with 4 children; he does not drink alcohol and does not
smoke. He relates well with his neighbors and friends. He had good social relation with people
of his community prior to onset of illness.
Past Medical History:
Patient was once admitted to Federal University Teaching Hospital, formally known as Bauchi
Area Specialist Hospital with the diagnosis of Inguinal Hernia.
Present medical history:
Mr. An was admitted on the account of abdominal pain, vomiting and constipation for 3 days.
Physical assessment: (Head to toe)
Hair: Bald
Face: Black with visible wrinkles.
Eyes: Deep into the socket.
Eyebrow: Black and grey, well aligned.
Nose: Normal and well aligned.
Mouth: Appears dry but no ulceration.
Ear: Normal
Chest: Heart sound is normal
Upper Limbs: Normal
Abdomen: Distended and tender to touch.
Pelvic region: Pain around the groin and waist.
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Lower extremities: Inability to walk properly with legs, no edema and nails are scant.
Inspection:
Patient was brought into the ward in company of his first son and daughter, with distended
abdomen and dry skin, weak and dehydrated.
Palpation:
Abdomen was tender to touch.
Auscultation:
Auscultation reveals no sound around the abdomen cavity due to little or no peristaltic
movement and accumulation of fluid.
C. RECORD OF SPECIAL INVESTIGATION
Hematology
1. PCV - 36%
2. Blood group – BRH ‘O’ Positive
3. RBS - 7.8mmol/L
4. WBS - 5.1 X 10^9
5. Neutrophils - 32%
6. Lymphocytes - 48%
7. Monophil - 20%
Clinical pathology report
BLOOD NORMAL RANGE
Na+ 147 135 - 165 mmol/L
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K+ 4.4 3.5 - 5.5 mmol/L
Cl- 103 95 - 106 mmol/L
HCO 3 29 21 - 31 mmol/L
Creatinine 82 72 - 126 mmol/L
Microbiology report
- Presence of Entamoeba cyst 1mm in diameter
- Results: mantoux positive
Radiology report
- Abdominal X-ray: the features are intestinal obstruction.
D. NURSING DIAGNOSIS
1. 1 Acute pain related to abdominal distension as evidence by patient's verbalization.
2. 2 Fluid volume deficit related to nausea and vomiting as evidence by decreased blood
pressure.
3. Anxiety related to crisis situation and changes in health status as evidence by decreased
attention span.
Nursing Care based on Identified Diagnosis and Objective.
1. Patient was educated about condition, including the causes of the condition.
2. Patient was enlightened on the consumption of dietary fiber to avoid occurrence of the
condition.
3. Prompt treatment of any infections instituted to avoid
4. Patient was given psychological and emotional support.
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E. NURSING INTERVENTION (DAY TO DAY PROGRESS NOTE)
DAY 1:
Patient was admitted into the ward/unit, prescribed medications were made available:
- IV Ceftriaxone 1.5g 12hrly
- IM Pentazocine 30mg 6hrly
- IV Omeprazole 40mg 12hrly
- IV paracetamol 600mg 8hrly
- IV Metronidazole 500mg 8hrly
- IVF 5% Dextrose + Water = Normal Saline 1ltr 8hrly
Vital signs checked and care rendered:
Temp - 36.5°C
Pulse - 80b/m
Respiration - 20c/m
BP - 110/70 mmHg
SPO2 - 96%
DAY 2:
7am - Patient met calm on bed on talking overslept with the medication served, alongside vitals
signs checked and recorded.
Temp - 37.1°C
pulse - 120 b/m
Resp - 22 c/m
BP - 120/80 mmHg
DAY 3
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Fun patient was met calm on bed on taking over shift, extra due nursing care rendered,
medication served and charted alongside vitals checked and recorded
Temp - 36.9°C
pulse - 92 b/m
Resp - 20 c/m
BP - 110/70 mmHg
DAY 4
Fun patient was met calm on bed on taking over shift, routine care was given (bath and oral
care), medication served and charted, vital signs checked and recorded
Temp - 36.8°C
pulse - 76 b/m
Resp - 20 c/m
BP - 100/70 mmHg
F. HOME CARE
The following home care was made on 20th March 2025,
patient was met calm at home and was advised on the following;
1. He was advised on the importance of adhering to his medication, in order to prevent
resistance.
2. He was advised to maintain environmental and personal hygiene.
3. Patient was enlightened about getting pressure to good health to prevent pressure
presents reoccurrence of the condition.
4. He was educated on the importance of food and nutrition (high protein, vitamins)
and to maintain fluid intake (water)
5. Patient was encouraged on follow up appointments
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G. NURSING CARE PLAN
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