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Family Case Study Cholera Disease Patient

Family Case Study Cholera Disease Patient

CHAPTER ONE

INTRODUCTION

This is a family case study of Miss A.G, a 10 year old pupil of Divine Grace primary School Izzi, living with her parents at No 3 Ukpo street Izzi, Izzi local government area of Ebonyi State. My first contact with the family was on 28th February 2015 when Miss A.G reported at the outpatient clinic of Nwaezenyi comprehensive health centre, Izzi Ebonyi State accompanied by mother and father with the complaint of frequent watery diarrhea and vomiting, malaise, dryness of skin and mucus membrane and fever that has lasted for 4 days.

After obtaining the history from the client’s relative, initial physical assessment and vital signs were also carried out. She was taken to the medical officer on duty who after examination referred her to the laboratory for further investigations, after  which the diagnosis of cholera was made.

Appropriate medical and nursing care was given to the client and she was discharged on 8th March, 2015 with a good prognosis. This study also contains all the nursing and medical management carried out on each home visit.

Case study background

Miss A.G, a 10 year old primary school pupil was born into the family of Mr and Mrs. G.O 9th October, 2004. her delivery was conducted at home by a trained tradiational Birth attendant without complications. She was brastfed for a year and circumcised on the 9th day of her birth (ditoridectomy). She is not properly immunized (has been immunized only twice since birth) due to parent’s poor knowledge about immunization.

Since birth Miss. A.G has suffered bouts of illnesses ranging from stomach ache, fever, headache but was treated with local concoctions and drugs bought from the local chemist shop. Her present problem began on the 24th of February 2015 around 1a.m when she started passing incessant watery stool and vomitus. She took the local concoctions (herbs) to no avail and when her parents noticed her deteriorating health condition, they decided to seek professional health by bringing her to the health centre.

Family social history

The client father’s name is Mr. G.O, a 47 year old farmer living at No 3 Ukpo Street Izzi Local government of Ebonyi. He is a Christain and worships at assembles of God Church. Her Mother’s name is Mrs. H.G, a 38 year old petty trader living at the same address with that of father and also worships in the same church.

Miss A.G is the fourth child in a family of 9 children made of 5 females and 4 males.

FAMILY HEALTH HISTORY (PAST AND PRESENT)

The family have suffered different kinds of minor ailments in the past ranging from stomachache, headache, fever, cuts e.t.c. They usually treat these health problems with local concoctions and drugs bought over the counter from the local drug seller (local chemist shop) located in the village market. They respond to treatments from these local concoctions and over the counter drugs. Nil history of appendicectomy, hypertension, diabetes, Asthma.

Present medical history of the client

Miss A.G was apparently well until 4 days prior to admission to the health centre when she started passing incessant watery stool, vomiting leading to weakness and dryness of skin and mucus membrane and fever. She was brought to the health centre and after series of laboratory investigations, the medical officer diagnosed her of cholera disease.

Investigations

  • Physical Assessment: Shows dryness of skin and mucous membrane, loss of skin tugor, sunken eye balls, pale and flushed face and weakness.
  • Vital signs: Blood pressure – 80/60mmHg, pulse- 11b/m, respiration – 45c/m, temperature – 38.60C, weight – 28kg.
  • Packed cell volume: 25%
  • WBC – Normal
  • Malaria parasite – positive
  • Widal test – significant titre
  • Retroviral test – Negative
  • Stool microscopy – Fresh faecal specimen reveal the shooting star motility of the vibrios which halts abruptly if 01 antiserum is added to the slide.

Miss A.G was diagnosed of cholera disease after the tests result were ready. She also has malaria and typhoid fever which were also treated.

Objectives of the study

  1. To identify the possible causes of the disease and intervene.
  2. To health educate client and family members on the need for personal and environmental hygiene, proper waste disposal, water purification process and adequate ventilation.
  3. To establish friendly and lasting relationship with the family for the purpose of promoting health.
  4. To conduct contact tracing inorder to elicit symptomless carriers and make sure that other members of the family is not affected.
  5. To enable client and family to see health as a valuable asset.
  6. To ensure that client adhere strictly to drug regimen and other therapies e.g oral rehydration therapy.
  7. To identify other health and social problems facing the family and proper solution to them.

 

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