By | July 14, 2021


Madam R.A wakes up at 4:30am in the morning and retires to bed at about 9:00pm. She brushes her teeth and takes her bath with warm water. Afterwards, she takes her breakfast and goes to the farm. She comes back at about 1:00pm to prepare lunch, she sometimes carries lunch along to the farm therefore comes back late. She rests after eating and prepares supper at 5:00pm. She eats three times daily but sometimes twice a day. Her favourite food is banku with groundnut soup. She baths twice daily and visits the toilet every morning.

On Saturdays, she stays at home all day and sometimes visits her friend when she is bored with staying at home. On Sundays she goes to church very early to help sweep the church before service begins. At her leisure time she sits under the tree in their house and listen to radio.


Madam R.A has no chronic disease neither has she under gone surgery. She has no known allergies. She goes for regular check-up especially when she is not feeling well. She does not rely on over the counter medications but seeks medical care whenever she has a problem.

She normally visits Ho Municipal Hospital and her last visit to the facility was in April 2019.



Madam R.A was well until Saturday 2nd November 2019 when she experienced severe epigastric pain which started gradually. She said the pain increases when she eats and was vomiting as well. The pain made her uncomfortable, restless and unable to breathe well. According to her, it made her very weak and on the fifth day she was rushed to the hospital.

She was sent to the Emergency Unit where she was managed. She complained of abdominal pain and persistent vomiting for two days. She was later transferred out to Female Ward.



 There are two types; planned and unplanned admission. In the case of my patient, it was unplanned admission.

On Saturday, 7nd November 2019, Madam R.A was admitted to the Female Ward from the Emergency Unit by Dr Osei with the history of abdominal(epigastric) pain, nausea, vomiting and weakness. She was wheeled into the ward accompanied by a nurse and two relatives. She was fully conscious. They were welcomed at the nurse’s station and offered chairs to sit on. Her folder was handed over to the nurse in charge to cross check whether she was the right person at the right ward.

She was put into an already prepared bed. An intravenous line was secured with IV Ringers Lactate 1litre set up. She was reassured and her vital signs were checked and recorded as follows:

       Temperature                                               36.8 degrees Celsius

       Pulse                                                           98 beats per minute

       Respiration                                                 22 cycles per minute

       Blood pressure                                            120/80 millimetres of mercury

The following medications were administered per the doctor’s orders:

     IV Omeprazole                                                    80mg stat,

     IM Metoclopramide                                            10mg stat,

     Ringers Lactate                                                   1 litre over 6 hours.

The problems identified on admission were severe abdominal(epigastric) pain, persistent vomiting for two days, body weakness and anxiety. Nursing process was used in the plan of care for the patient.

She was put on the following medications:

    Caps Omeprazole                        20 milligram bd x 14 days

    Tablet Clarithromycin                 500 milligram bd x 14 days

    Caps Amoxicillin                         500 milligram tid x 14 days

    Tablet Paracetamol                      1-gram tds x 7 days

    Tablet Metoclopramide                10 milligram daily x 5 days

    Ringers Lactate                            1litre over 12 hours

    Dextrose normal saline                4litres over 48 hours

 The following laboratory investigations were requested;

  1. Full Blood Count
  2. Albumin Level Estimation
  3. Globulin
  4. BUN Level Estimation
  5. Blood Creatinine
  6. Routine Stool Examination.

Samples were collected and sent to the laboratory. Madam R.A and family were later oriented to the ward and introduced to other staff and patients around her. Ward routines were also explained to her. I took the opportunity to introduce myself and seek for her consent to be her special nurse, during her stay in the hospital, who will care for her and the family with the help of the other nursing staff and write patient/family care study on her condition. I assured her of confidentiality of every information. She accepted the request and assured me of her maximum cooperation.

Patient’s name and date of admission were noted and recorded in the admission and discharge book, admission papers, daily ward’s state and were documented in the nurses’ notes.


She said that it was normal for one to fall sick, but hers’ was too severe. She also believed that, with God’s healing through good nursing and medical treatment, she would have a complete recovery.

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