The Medical History with the Effective Management Plan for the Patient - Assignment Example

Running Head: Clinical Scenario 2 Name Course Lecturer Date Q1) Taking of the medical history is part of the entire process of collecting cues from the patients in order to come up with the effective management plan for the patient. The medication history will involve the interviewing of the client. I would go ahead to introduce myself to the client with all my names and my profession and go ahead to inform the patient why I would desire to have the moment with him to ask him the questions. this will be followed by an inquiry on any possible medication that the client was currently taking or is continuing to take at that time. If there is any medication the client was on, I would ask Nick Morris to give the name of the medication, the dosage of the medication, the route of administration of the medication, and the possible reasons why he was put on that medication. I would then make an inquiry on the whether the medication was a prescription or over the counter, and whether the patient is on any herbal medications. I would find out whether there was any recent change of medication or dosage that was done in the patients recent medication and the possible reasons why the changes were made if yes. The effectiveness of the medication will then have to be explored and this would involve finding out if the patient reports any side effects while using the medication or instances when talking the medication the client feels worse or any other forms of allergies (Swash & Glynn, 2007). The compliance of the patient to the medication will also have to be established by finding out if the patient has been adhering to the medication to the later and that no defaulting was reported in the entire period. due to the client being form the aborigine community which is deeply enshrined in the taking of traditional medicines, there will be need to find out more information with regards to the patient having sought the use of the traditional medicines at the onset of the condition he is having. there will also be need to carry out client education and this will involve informing the client on the importance of always having the list of current medications when visiting the hospital, encourage one pharmacy and also the involvement of family members or care givers. I would also inform the client on the importance of medications and how to best take the medication to enhance the efficacy (Swash & Glynn, 2007). Q2) The post operative care for Nick Morris would be aimed at preventing, detecting and preventing complications or physiological derangements that may occur with the aim of minimizing chances of morbidity and mortality that will be related to surgery and anesthesia. Components of the post operative care will include monitoring, pain relief and other specific prescriptions. In the assessment of Nick Morris, there will be need to conduct a full physical examination. There will also be need for various diagnostic methods to be used in the assessment. After surgery , the patient will be taken to the post anesthesia care unit where the patient will stay until the anesthesia wears off. At this time the nurse will be taking the vital signs at frequent intervals until the anesthesia wears off and the vital signs attain stability (Bristow, 2004). The severity of the patient pain will then have to be assessed using the pain scale. An appropriate pain relief medication can then be administered. This will enable the determination of the best way to managing the pain that the patient will be having. Monitoring of the vital signs should be done at regular intervals at half hourly for two hours postoperatively, hourly for two hours and every hours while the patient is undergoing recovery in hospital. Vitals will provide information on the general well being of the patient or show if the patient is having complications as a result of the surgical procedure. The eight general parameters which include pallor, jaundice, cyanosis, dehydration, oral thrush, finger clubbing, and edema will also have to be taken. Normally in this patients a drain is inserted thus the output of the drain that was inserted during surgery will also be monitored with the output recorded every 24 hours. The drainage will then be removed once there is minimal drainage which is usually 50ml or less. The wound will also be managed aseptically this means that high standards of hygiene are to be maintained at the site of the wound. Changing of the dressing of the wound should be done after every 1to two days . Stitches or clips will have to be removed ten days postoperatively. The patient will be informed on how to take care of the wound when being discharged. Nick will also be informed on how to clean the site of the wound to avoid contamination. Monitoring of the patient for the possibility of infection will then be carried out. the site of incision will also be observed whether it healing well or not. I would then inform the patient how infection occurs and what signs would characterize the infection (Bristow, 2004).Ambaralation should be encouraged by allowing the patient to get out of bed as soon as possible. The Ambaralation will be aimed at preventing the patient from formation of emboli. Anticoagulants will also be administered in the form of subcutaneous injection before and even postoperatively. Some patients could also be given pressure stockings to prevent the formation of the emboli. This patients will tend to have dehydration hence the morning that is after surgery, Nick Morris will be offered with clear fluids. Once they are tolerated the diet will gradually progress to solid foods. The intravenous line is removed once the patient is eating. Physical movement of the patient should begin on the same day of surgery or the next day (Williams et al, 2011). Q3) Immunization still remains the primary way of preventing most disease. There is need for nick to be screened before the immunization is done. The screening enable the identification of the right patients who are to undergo immunization. Some disease conditions that one has might not allow all to undertake immunizations and thus the screening process will enable the groups that can be immunized to be clearly identified. This will enable only the rightful persons who can be immunized to undergo the procedure. When those who should have disease conditions which do not allow immunizations to be done like in the case of immunosuppression, the screening will prevent them from getting infected especially when the live vaccines are used on them since they will not induce an immune response but will trigger the occurrence of the disease process in the individual. Screening therefore enables the process to have efficacy since only those whom are to benefit from vaccinations will be immunized. Opportunistic immunizations will thus be effective in the prevention of various infections since those immunized individuals would have had immunity conferred to them after having under gone the process of immunization. Nick will thus be able to benefit from the entire opportunistic immunization screening since he will be able to be immunized and this will go a long way to confer immunity to him by preventing him from various infections. Most of the Aborigines would use traditional medicine and most of the immunizations have not been conducted to most of them hence they have a high predisposition to getting infected and this is supported by the high statistics they pose in terms of those having ill health presently in Australia. This would be an opportune moment that nick will have to be able to benefit fro the immunization programs since Aborigines tend to shy away from the health facilities as a result of being so deeply enshrined to their culture and traditions (Ressler et al, 2008). Q4) Cultural factors affect the way health services are administered amongst numerous populations in the world today with the Aborigines in this case not being an exception. the Aborigines post the highest statistics of those who have ill health. This is so because of the beliefs they have about the health care system with One of them being the belief that it is unsafe to stay in hospital. The belief that hospitals are unsafe has been a misconception among the Aborigines and this has greatly been attributed by them being so much deeply rooted in their culture. Aborigines should be counseled and made to understand the importance of embracing health to an individual as well as being informed on how they can be able to prevent diseases. Information should also be relayed to them so that they can be able to make informed choices about their own health issues. The Aborigines should therefore be educated on how to prevent the occurrence of certain diseases which are preventable. They should also be made to know that better prognosis will be enhanced by them being able to seek early medical intervention but not shying away from the hospitals to get medical attention. In this case, the Aborigines should be made to realize that it is only in the hospitals that they will be able to get the best health care services as well as medical attention. When they stay in hospital, they will be attended to in the deserving manner that will promote their well being or recovery. Staying in hospital would enable them to be monitored regularly till they are able to recover and are free from danger of succumbing to the disease condition. In the case of Nick, he should be counseled and given information about his health and the importance of him staying in the hospital. He should be made to understand that for him to attain full recovery, there is need for him to stay in hospital so that he can be monitored by the health care workers so that they can fully be convinced he is free from possible complications and the treatment given will yield to the desired out come. Nick should also be asked to encourage members of his community not to fear staying in hospitals since it is intended to make their health to be better. This will prevent other Aborigines who will need to be admitted in hospitals to understand the importance of staying in the hospitals. This will bring positive result s to the community due to health being given priority among the Aborigine population (Victorian arboriginal health services, 2011). Q5) There will be need for the nurse to be able to inform nick on how he will be able to attend to his condition while at home. Nick will have to take care of the wound and ensure that it is clean and always dressed until full recovery is attained. He will also be advised to avoid strenuous activities till recovery to avoid the dehiscence of the wound. Nick will also be informed of the signs of the wound being infected so that he might be able to seek medical attention before being overwhelmed by the infection. Nick will also be advised on how to take the medication that will be given to him which would include the pain relievers and the antibiotics. The pain relievers will be used to relieve the pain whereas the antibiotics will provide cover from infections. I would also ensure that Nick is aware of the dosages of the medication, when to take the medication and when he will stop using the medication. Information relating to the various side effects of the medication will also be relayed to nick. Information regarding to signs that nick will be able to know if his condition detoriating will also be relayed to him. This will include features such as fever , tenderness which are which would be a clearly indication of the patient being overwhelmed by infection and this would prompt nick to seek medical attention (Williams et al 2011). Reference Swash M., Glynn M., (2007). Hutchison’s Clinical Methods: An Integrated Approach to Clinical Practice, Saunders Ltd, Edinburgh. Bristow N., (2004). Treatment and management of acute appendicitis, VOL: 100, ISSUE: 43, PAGE NO: 34 East Surrey Hospital, Surrey. Ressler K.,Orr K., Bowdler S., Grove S., Best P., Ferson M., (2008). Opportunistic immunisation of infants admitted to hospital: Are we doing enough? The Authors. Journal of Paediatrics and Child Health Division (Royal Australasian College of Physicians). Williams N., Bulstrode C., O'Connell P., (2011). Appendicitis ,Bailey and Love's Short Practice of Surgery 25th Edition, Hodder Arnold Publication, United Kingdom.. Victorian aboriginal health services, (2011). Caring for the community Retrieved from http://www.vahs.org.au/ on 16th September, 2011. Read More