WISCONSIN INTERNATIONAL UNIVERSITY COLLEGE, GHANA

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF GENERAL NURSING

GUIDELINES FOR WRITING PATIENT/FAMILY CARESTUDY

FOR

BACHELOR OF SCIENCE IN GENERAL NURSING

(REGISTERED GENERAL NURSING)

MAY, 2018
 PATIENT/FAMILY CENTERED CARE STUDY

ON

A PATIENT WITH (insert patient condition block letters)

COMPILED BY;

(Candidate official name in block letters)

ALHASSAN A. SIBDOW

(LICENSURE INDEX NUMBER)

622015035

A FINAL YEAR STUDENT OF WISCONSIN

INTERNATIONAL UNIVERSITY COLLEGE, GHANA
SUBMITTED TO NURSING AND MIDWIFERY COUNCIL
OF GHANA IN PARTIAL FULFILLMENT OF THE AWARD
OF REGISTERED GENERAL NURSING LICENSE
(HOSPITAL WHERE THE PATIENT WAS TREATED)
37 MILITARY HOSPITAL, ACCRA
MAY 2018
PRELIMINARY PAGES

PREFACE

1. Reason for carrying out study

2. Necessity for carrying out the study

3. Help it offers the student

ACKNOWLEDGEMENT

Expression of gratitude to the following

1. The patient/family and why

2. Tutors and why

3. Ward staff and why

4. Any other persons etc INTRODUCTION

State the following in brief

1. Use a pseudonym for patient for purposes of confidentiality

2. When the interaction started

3. How it started

4. How long it lasted

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5. The patient condition on admission

6. History of the chief complain

7. The patient condition on discharge

8. Areas covered in the report

NB. The introduction should not be more than one page

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 CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

1.0 Introduction

Areas to be

covered Sources of

data Purpose

1.1 The Patient’s Particulars

 Name

 Age

 Sex

 Religion

 Marital status

 Ethnicity

 Nationality

 Number of children

 Educational background

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  Languages spoken

 Height, Weight

 Address: House number, Name of tow, Cell phone number, (email address if possible) 

Next of kin

 Family doctor (if applicable)

1.2 The Family Medical History

 Any chronic disease in the family and whether it has been treated

 Any hereditary disease like essential hypertension, diabetes mellitus, sickle cell disease,

mental illness, Heart disease, Cancer, Hyperlipidaemia (high cholesterol), Obesity

Allergies, Arthritis, Bleeding etc.

 Any communicable disease like TB, leprosy

etc Any drug or food allergies

1.3 Socio-Economic History

 Type of family (nuclear, extended/single parenting)

 Occupation (client/spouse/family)

 Total number of dependents

 Contribution each makes for the up keep of family

 Social activities like funerals, clubs belongs to part plays

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1.4 The Patient’s Developmental History

 Place of birth (Home or Hospital)

 Mode of delivery & circumstances surrounding birth (spontaneous, instrumental,

prolonged labour, APH etc)

 Childhood immunization

 Developmental milestone

 Infancy: Age child started sitting, crawling, walking, talking (speech) toilet training etc.

 School age; age at which he or she started schooling if educated

 Adolescence: Onset of puberty (Onset of secondary sexual characteristics)

 Age at which client started working

 Life experiences of patient (e.g. Loss of spouse or child, Onset of puberty, Menopause

Etc.

 Age of retirement (where applicable)

1.5 The Patients Lifestyle and Hobbies

 First thing done before getting out of bed

 Last thing done before getting to bed

 Routines from morning to night on an average day

 What is done at leisure times

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  Food habits – What he takes at breakfast, lunch and supper

 What he drinks and amount taken in

 Personal hygiene-number of times bath daily and why that frequency

 Type of water used in bathing (hot, warm, cold)

 Type of soap used in bathing

 Whether client uses towel and sponge to bath

 Times of pasting and type of paste and why

 Frequency of elimination etc.

1.6 Past Medical / Surgical History

 Any disease the patient has ever suffered from and how they were managed

 Any hospitalization and duration (date, diagnosis, place of treatment etc.)

 Childhood illnesses- chickenpox, mumps, measles, other significant illnesses

 Accidents and injuries: how, when and where the incident occurred, type of

injury, treatment received and any complications

1.7 Present Medical History

 When the present condition started (date & time)

 How it started i.e. rapid or gradual onset

 What had been done before patient was brought to hospital

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  Name of hospital client was admitted to and name of the attending physician

1.8 Admission of the Patient

Describe the admission process (specific to the type of patient whether adult or paediatric).

State of patient at the time of admission

Time and how he was admitted

Reception of the nurses (welcoming patient & relatives)

Whether he came alone for or accompanied by somebody

What was done for the patient by the student nurse:

 Self-introduction of student and staff

 Looking through patient papers to gather more information

 Entry of particulars into admission and discharge book

 Introduction of patient to other patients

 Taking of vital signs

 Education on ward routines-visiting hours, time, rounds etc

What is expected of the patient and family etc

Refer to the standard procedure manual for nurses for further information on the admission

process

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 1.9 The Patient’s Concept of Illness

 What the patient thinks is the cause of the illness

 Patient’s understanding of the condition

 The patient’s concern of the illness

 The patient’s expectation of treatment

1.10 Literature Review on the Condition

 Definition of the condition

 Types

 Incidence and explain how

 Aetiology

 Pathophysiology

 Clinical features

 Diagnostic investigations

 Specific medical and surgical treatment

 Nursing management

 Complications

NB: All literature used should be appropriately cited preferably using APA format.

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1.11 Validation of Data

State areas of validation and why (Conflicting information, doubt etc) NB:

 Information collected from patient & relatives should be consistent with that from

other health workers

 The s/s and diagnostic investigations should equally be consistent with the literature

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 CHAPTER TWO

ANALYSIS OF DATA

2.0 Introduction

 Areas to be covered

 Purpose

2.1 Comparison of Data with Standards

a. Diagnostic investigation/test (this should be in a tabular form) e.g. Table

2.1 Diagnostic investigations
Date Specimen Investigation Result Normal value Interpretation Remarks

27/04/15 Blood Haemoglobin 5g/dl 18g/dl Below normal Blood and

level estimation indicating haematinics
severe anaemia ordered and
administered

Please state the percentage of diagnostic investigations which confirmed your patient condition.

b. Causes

State factors that brought about the condition and indicate whether or not the factors are
consistent with literature.

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c. Clinical Features

State the signs and symptoms shown by patient & compare them with those in the literature e.g.
Table 2.2 Comparison of clinical features
NO. Clinical features in literature Features exhibited by client

1 Fever Fever present(T 38.9)

2 Cough Present; Client had productive cough

3 Dificulty in breathing(Dyspnoea) Client experienced difficulty in breathing

4 ..……etc.

Statement of comparison

Please state the percentage of the clinical features your patient presented comparative to the

literature.

d. Treatment

State the specific medical/surgical treatment that has been given to your patient & compare

that with the literature. If a particular drug has been discontinued state the reasons for

discontinuation.

List drugs that were prescribed for your client as follows:

1. Tabs. Paracetamol 1g tds X 3days

2. I.V ceftriaxone 1g stat

3. Caps amoxicillin 500mg tds X 5days

4..............etc.

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NB: Pharmacology includes i.v fluids and should be tabulated as shown bellow:

After listing the drugs, students should explain pharmacology of drugs in a table as given below: Table 2.3 Pharmacology of
drugs
Date Drugs Standard Dosage ＆ Classification Desired effect/ Actual Side effects
Dosage/ Route of mechanism of Action ＆
route of Administration for action Observed Remedies
administration in patient
literature

Tab paracet 500mg – 1000mg. 1g tds x 3. Analgesic and Blocks pain impulses Reduce d Liver
amol antipyretic and lower body patient damag
temperature temper e
Route Route
ature and drowsi
Orally Orally chest ness
pain headac haemo
he lytic
anaemi
a

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Tab Cefuro 500g bd Second Inhibits cell wall Bacteri al Confus
xime 250 – 500 mg ×7/7 generation synthesis infectio n ion,
cephalosporin of sensitive was curb seizure
antibiotics organisms causing s
Route Route
this death nausea
Orally Orally
,
vomiti ng
and
diarrho ea

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16
Note: ALL TABLES MUST BE PRESENTED IN LANDSCAPE

Students should use the generic names of drugs instead of trade names

Students should write the specific classification of drug and not the broad group. E.g.

Fluoroquinolone and NOT broad-spectrum antibiotic, Loop diuretic not diuretic

e. Complications

With reference to the complications in the literature, state the complications of your patient

developed and how they were managed.

2.2 Patient Health Problems

Provide brief introduction of what constitute patient and family problems.

Actual health problems-an unmet health need that the patient presents with. Potential health

problems-problems the patient is likely to develop due to his/her present health status. The

patient’s problems should be stated just as patient complained or as seen by the nurse e.g. “I

cannot walk”. Identified problems should be prioritized based on the Maslow’s hierarchy of

human needs.

NB: The patient’s strengths and problems should be chronologically arranged such that each

strength corresponds to a health problem that it is meant to address i.e. the first strength addresses

the first problem, second strength addresses second problem etc.

Students should state five specific strengths and three general strengths.

2.3 The Patient/Family Strengths

Provide brief introduction on what constitute strengths of a patient and family.

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General strengths- not related to a specific health problem but facilitates general nursing

management of patient e.g. e.g. client being on NHIS, being able to talk, walk, bath etc.

 Specific strengths-relates basically to the client’s problems e.g.

 Problem: Patient lacks knowledge on treatment

 Strength: Patient is ready to comply with treatment

 Problem: Patient has severe diarrhoea

 Strength: Patient drinks copious amounts of fluids

2.4 Nursing Diagnoses

Provide brief introduction on nursing diagnosis relative to the concepts as discussed by current
NANDA. Remember that a nursing diagnosis generally is the Health problem of
patient/family related to the etiology or cause or pathology.
This is derived from the health problems - 2 part nursing diagnoses should be used for both
actual and potential health problems e.g.

 Deficient fluid volume related to active fluid loss from the body secondary to

severe diarrhoea –actual

 Risk for impaired skin integrity related to immobility

Nursing diagnoses should be prioritized based on Maslow’s hierarchy of human needs

NB: Never use “potential or high risk” in writing nursing diagnoses; instead, use “risk for”

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THE PROBLEMS AND STRENGTHS OF PATIENT AND FAMILY MUST BE
GROUPED INTO GENERAL (3) AND SPECIFIC (5) FOR STUDENTS WRITING ON
MEDICAL CASES

FOR STUDENTS WRITING ON SURGICAL CASES, THE PROBLEMS, STRENGTHS,

AND DIAGNOSIS MUST BE GROUPED INTO PRE-OPERATIVE (6) AND POST
OPERATIVE (6)

All the tables must be presented in landscape format.

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 CHAPTER THREE

PLANNING FOR PATIENT/FAMILY CARE

3.0 Introduction to the chapter:

 Areas to be covered

 Purpose

3.1 Objectives

Desired outcome or change in the client’s condition. They are based on the problems identified in

2.3

Objectives must contain action verbs

E.g. The patient will regain normal sleep pattern within 48 hours or

The patient will attain normal sleep pattern within 48 hours

Usually for actual health problems it is recommended to use the verb ‘regain/attain’ and for risk

health problems use the phrase….. ‘Client will maintain’ in formulating the objectives.

Objective/outcome criteria

Generally in stating objectives, candidates are expected to use the SMART RULE. Where

S=specific, M= measurable, A= attainable, R= realistic, T= time bond.

In developing objective/outcome criteria for potential problems, the aim is to prevent the client

from developing the anticipated problem. In the case of an actual problem, the aim is to move the
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patient from the problem state to the previous state of being (wellness state). The objective or

outcome criteria should relate to the nursing diagnosis

State the objective in active language e.g. (a) client will experience relieve of anxiety within

48hrs: evidenced by client verbalizing relieve of anxiety.

Provide an indicator (criterion) for achievement (evidence of achievement demonstrated by

patient of family) client will experience relieve of anxiety within 48hrs, evidenced by:

1. Client verbalizing relieve of anxiety.

2. Relaxed facial expression

Objectives should be categorized into short term and long-term objectives

Short term: 72hrs

Long term: beyond 72hrs/ weeks/months.

Note: Avoid using “will not and will be” in formulating nursing objectives Students

should State two outcome criteria.

3.2 The Nursing Care Plan

Draw a table with the following.

1. Date and time –when the diagnosis was made

2. Nursing diagnosis as they appear on chapter two e.g. sleep pattern disturbance related

to the lighting system (bright light)

3. Objectives/outcome criteria e.g. Nana will regain her normal sleep pattern within

48 hours; evidenced by Nana sleeping for 8 hours

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4. Nursing order – specific instructions or individualised activities nurse performs on a

patient to achieve a stated nursing objective or resolve a specific health problem.

Start with a command and action verb. The time element defines how often the order

will occur. E.g. Turn patient every 2hrs. Dim light in the cubicle etc.

5. Nursing interventions e.g. the light was dimmed by closing window blinds to promote
sleep
6. Date and time
7. Evaluation e.g. Goal fully met; Nana slept for 8 hours. Note very well that the

entire outcome criteria must not be repeated in the evaluation column in the care

plan.

Candidates are encouraged to avoid lifting the two outcome criteria with the usual

phrase….as evidenced by. Evaluations should therefore be stated as shown in the table

below

8. Please ensure that the orders are interventions are well balanced. Thus, the orders and

interventions address both the problem and the cause. Example If you have a diagnosis:

Impaired gas exchange related to pulmonary tissue inflammation and accumulation

of secretions on the airway

The orders must address the impaired gas exchange (in this case the problem) and the

cause (in the case pulmonary tissue inflammation and accumulation of secretions on the

airway)

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TABLE 3.1 SAMPLE NURSING CARE PLAN

Nursing Objective/Outcome Nursing intervention

Diagnosis criteria Date/Time

Date/Time Nursing orders Evaluation Sign

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03-09-15 Deficient fluid Client will regain normal 1. Assess 1. Patient was 05-09-15 Goal fully met;
volume hydration status within degree of assessed for client had moist
12:30pm FVD dehydration 2x 1:00PM skin and mucous
deficit related 48hrs evidenced by:
membranes with
to severe 2. Administer daily
1. observing client normal urine
diarrhoea IVFs as 2. Intravenous 4L of
having moist output
ordered N/S was
skin and 3. Monitor & administered in
mucous record fluid 48hrs as ordered
membranes I/O 3. Patient IVFs,
drinks, urine,
2. normal
……….up to vomitus were
urine output
monitored as I/O
and recorded
EIGHT(8) orders
……….up to
EIGHT(8)
interventions

AAS

Please see Table 3.2 for a complete care plan with balanced orders and interventions

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Table 3.2 Nursing care plan
Date Nursing Objective/ Nursing orders Nursing intervention Date & Evaluation Sign
& diagnosis outcome time statement
Time criteria
Short term
14/01/23 Acute pain Patient will 1. Assess patient’s 1. Patient pain level was assessed to be 4 15/01/23 Goal fully SOA
@ (epigastrium) demonstrate level of pain on a pain scale of 1-10. @ met as
2. Assist patient to 2. Patient was assisted to assume
10:00 related to relieved of 10:00 am patient pain
assume a a supine position for comfort.
am ulceration of pain within comfortable 3. Vitals monitored and recorded as has reduced
the duodenal 12 hours position temp-36.4 oC , pulse- 77bpm, resp - and nurse
and gastric evidenced 3. Monitor baseline 20cpm, bp-123\76 mmHg,spo2- observing
mucosa from by: vitals 95%,wt -65kg. patient is
a) Patient 4. Administer 4. Cap esomeprazole 20mg PO, susp.
increased relaxed in
verbalizing prescribe ulcer Megacid 15mls PO were served as
acid. medications ordered to manage the ulcer. bed
the
absence of 5. Provide 5. Patient was engaged in conversation
pain diversional therapy to help draw his attention from pain
b) The nurse 6. Administer 6. Injection hyoscine butyl bromide 20
observing prescribed mg stat was administered to relieve
patient is medications pain.
relaxed in 7. Educate patient on 7. Patient informed about the risk factors
bed and condition and of PUD including stress, starvation,
have a reason for pain and advice to complete the treatment.
good facial 8. Reassure patient 8. Patient and relatives were assured of
expression and relatives of providing quality services to enhance
quality health care. the recovery process.

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THE CARE PLAN TABLES MUST BE LABLED FROM TABLE 3.1……….TO TABLE
3.8

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STUDENTS WRITING ON MEDICAL CASE. FOR STUDENTS WRITING ON
SURGICAL CASE, THE CARE PLAN MUST BE GROUPED INTO PRE-OPS CARE
PLAN (5) AND POST OPS CARE PLAN (5)

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 CHAPTER FOUR

IMPLEMENTATING PATIENT/FAMILY CARE

4.0 Introduction

Areas to be

covered Purpose of

Chapter

4.1 Summary of Actual Nursing Care

This is a brief report on the actual nursing care rendered to the patient/family from the time of

admission to the time of discharge or till s/he leaves the hospital or even die

It should be organized on daily basis for the first week and thereafter, on weekly basis in the

subsequent weeks . It must be consistent with care plans developed in chapter 3.

Summarize nursing interventions and spell out the reasons behind those nursing interventions.

This should correspond with the nursing care plan including care of bed after discharge

Routine care on daily basis should be added

Pre-discharge visit, discharge and review dates should be included

In the event that the patient dies on or after the fifth day, the student should carry out last offices.

In this case however, the student should visit the family of the deceased to serve as the follow-up

or home visit.

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4.2 Preparation of Patient and Family towards Discharge and Rehabilitation
Starts from day of admission and includes educating patient and family on:

 Aetiology of the condition

 Steps to prevent relapse of the condition

 First aid management before hospitalization

 Drugs

 Review date and its importance and home visiting and its importance

 The report should include the discharge process

 Identification of long term needs of the patient and persons responsible for cations to be

taken

 Identification of community resources that may be needed after discharge.

 State specific referrals made etc.

 You may refer to nursing procedure guidelines on preparation of a patient for discharge,
education on condition, education on medication to comprehensively develop this section.

NB. State how patient or family/ significant others were prepared for discharge

4.3 Follow-up/Home Visit/Continuity of Care

Pre-discharge visit is the first home visit. Its purpose is to assess the home environment of your

patient and to identify resources for management of the patient after discharge.

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The patient should still be in the hospital

State when you made the visit and objectives for the visit

State how the objectives were achieved

State observation made- Distance and or duration to the home from college, Housing- number of

rooms, number of people sharing a room, source of water for domestic use, environmental

sanitation, refuse disposal etc

Whether there is health facility in the community

Subsequent Visits

State opportunity to visit client at home to assess his/her health status following discharge. The

following should also be stated:

 Date and Objectives of visit

 State how far objectives were achieved
 Head to be examination
 Vital signs
 Progress and complaints
 Health education given etc
 Please refer to the routine and special home visit checklist in the public health manual for
further guidelines
On the their and final day of the home visits, the client and family should be handed over to a

community/public health nurse for continuity of care

NB: The student is required to visit the home of the patient on three different occasions

including the pre-discharge visit. This should be done preferably on weekly intervals.

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 CHAPTER FIVE

EVALUATION OF CARE

5.0 Introduction to the chapter

Areas to be covered

Purpose of chapter

5.1 Statement of Evaluation

State the extent to which each objective/outcome has been achieved by patient e.g. Nana slept for

8 hours

Briefly state the problem and some of the measures put in place to achieve the objective.

If there were failures state why

Past tense should be used in writing evaluative statements. The date and time of setting the

objectives as well as date and time of evaluation should all be stated.

5.2 Amendment of Nursing Care for Partially Met or Unmet Outcome Criteria

This should be done when a client has made little or no progress towards achievement of an

objective.

The amended care plan should be on a separate sheet and start at the end of the original care plan.

State the failure and how they were amended. Amendment can be done by adding extra orders,

extending the period of time for managing the client or by modifying the diagnosis etc.
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5.3 Termination of Care

This is a gradual process that begins on the day of admission and end on the day the nursepatient

interaction stops; usually on the third (final) home visit. Involve the patient and relatives in the

care of the patient so as to gain necessary skills for independence and continuity of care.

State the resources or facilities the patient is to rely on for further treatment e.g. hand over to

community health nurses, family hospital, clinic etc

Patient and family members or relatives should be pre-informed about termination.

6.0 SUMMARY AND CONCLUSSIONS

Give a summary of the care rendered to patient/ family from the time of admission to the time of

discharge or when the patient left the hospital or died The summary should include at least the

following:

 Diagnosis

 Date of admission and discharge

 Nursing care rendered to the patient/family

 Number of days patient stayed on the ward

 Number of home visits and how care was terminated.

Conclusion

State the conclusions you have made from the patient/family care study.

Bibliography

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Student should use the APA format of referencing for all literature used in writing the report.

MISCELLANEOUS

The candidate must use the United Kingdom English throughout the document. The chapter

headings should be in block capitals, bolded and centred. Sub-headings should be lower case,

bolded and aligned to the left. Use times new roman font size 12 throughout the text. The whole

document should be double-spaced and justified. Page numbers should be in Arabic numbers and

centred. Preliminary pages should be in roman numerals and as well be centred. Use font size 11

for inside tables with single space. All tables should be numbered using the corresponding

chapter number i.e. tables in chapter two should be label Table 2.1, Table 2.1….etc; that of

chapter three should be label Table 3.1, Table 3.2, etc..

The cover should be well designed with green background containing the cover details.

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 BIBLIOGRAPHY

Include all sources of data used for the write-up under this section. This should not be less than

10 and must be in APA referencing style

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 ANNEXURE

CANDIDATE MUST PRESENT ANY SUPPLEMENTARY DOCUMENTS ABOUT THE

CARE STUDY.
THE SUPPLEMENTARY DOCUMENTS MAY INCLUDE SCANNED COPIES OF
DIAGNOSTICS, VITAL SIGNS, AND OTHER SPECIFIC THERAPY LIKE
INTAKE/OUTPUT CHART

THE ANNEXURE MUST LABLED AS….Annexure A,B,C..................etc.

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 SIGNATORIES
NAME OF CANDIDATE …………………………………………………..

SIGNATURE ……………………………………………………

DATE ……………………………………………………

NAME OF CLINICAL SUPERVISOR …………………………………………………..

RANK …………………………………………………..

SIGNATURE ……………………………………………………

DATE ……………………………………………

NAME OF SUPERVISORY LECTURER …………………………………………………..

RANK (NURSING) …………………………………………………..

SIGNATURE ……………………………………………………

DATE ……………………………………………………

NAME: HEAD OF DEPARTMENT …………………………………………………..

RANK ……………………………………………………

SIGNATURE ……………………………………………………

DATE ……………………………………………………

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