Key elements of the demographic data
Key elements of the demographic data
The demographic data provides the name of the patient as Mr. Kasim Al-Mutar. Provision of the patient’s name is necessary for identification purposes. There may be other patients with similar medical conditions to the patient in question. The name would, therefore, be used to identify the intended patient. Besides, it is for every nurse to know the patient he or she is attending to by name. The patient’s age which is 49 years is also indicated. Diseases have different effects on people depending on the age of the persons. Besides, administration of medicine dose is pegged on a patient’s age. The data also indicates the condition from which the patient is suffering from. Symptoms which the patient has shown for the condition have also been indicated. The diagnosis information regarding the patient’s condition and symptoms would enable the next nurse to also relate the two and provides confirmation that the symptoms are not meant for any other medical problem. The name of the condition has been provided as cholecystitis. That is necessary because the next nurse should know the condition for the symptoms. The previous nurse has further presented details indicating the patients HR as 126, BP as 100/45 and the temperature as 38.8. These diagnosis details of the patient would enable the next nurse the patient’s symptoms to his indicated condition. The details are also very helpful in deciding on the appropriate treatment to be administered to the patient.
The former nurse further indicated that the patient was pale yellow with dry mucus membranes. He had severe RUQ pain and had vomited two hours ago. In addition, the patient was asking to drink water. The information regarding the skin colour and the vomiting of the patient would enable the next nurse in determining whether to provide the patient with water or not and at what time. The pale yellow colour of the skin could also tell that the patient had stayed longer with the sickness and his body fluid might have dropped significantly. Finally, the previous nurse has provided a description of the person who has escorted the patient to the hospital. He has been escorted by his daughter who is 12 years old. The daughter is under age and hence cannot bear any responsibility. The health facility must therefore fully take care of the patient since the daughter is simply a witness who would observe how the father is being attended to. The presented scenario is a typical complaint about the age and gender. The presented symptoms such as vomiting, fever, and pain in the right shoulder and upper abdomen are those of cholecystitis. However, the fact that the patient has been escorted by a daughter of 12 year old speaks volumes. That alone may be an indication that the patient is elderly and neglected by his family members. He therefore could only get his younger daughter to escort him to the hospital.
Additional information that may be missing
The information regarding the period over which the patient has experienced the mentioned symptoms has not been provided. There should also be information indication the medical history of the patient ( Lundy K.S, Sharyn Janes, 2009). Such information would enable the next nurse to tell whether the patient has suffered from the condition before or not. The information is crucial in determining the kind of treatment that should be administered to the patient. In addition, there should be information showing if there is any medication that had been administered to the patient by the time he was being handed over to the next nurse. If any, then the description, dose and time of administration of the medicine should be presented to the next nurse. The information would be helpful to the nurse in deciding on the next course of action. Finally, it was necessary for the second nurse to be furnished with contact information of the patient’s close relatives. The patient has come to the medical facility in the company of an underage daughter. It is therefore necessary for the next nurse to have contact information of any other close family relative to the patient who could be reached in case of any problem or even consultation. Cholecystitis is a disease that affects mostly people who have had gallbladder problems, a disorder known as gastrointestinal (Anthony J. DiMarino, 2002). However, there is missing information regarding whether the patient was also suffering from the disorder or not. It was therefore necessary for the next nurse to be furnished with information regarding the performance of the patient’s gallbladder too.
Interpretation of what I currently know about the presenting problem
The patient is suffering from cholecystitis and has stayed with the condition for quite some time. He has lost a lot of body fluids as a result of the condition and he needed an urgent attention. The situation is evident by the fact the patient had turned pale yellow and had dry mucous membranes. The presenting problem has made the patient’s body temperature to significantly rise. The patient experiences a lot of pain, particularly on his tip shoulder. He has also had vomiting cases. All these are an indication that the patient has been dehydrated. He had requested for drinking water by the time that he was being presented to the second nurse. The expected assessment finding would be the need to restore the patient’s fluid level before further medication is administered to him. Another expected finding would be the possibility of gallstone disease alongside cholecystists. Cholecystitis is associated with gallstone disease. However, the symptoms for gallstone disease are not commonly visible in adult patients (Lippincott Williams & Wilkins, 2009).
Identification of problems and issues
Cholecystitis is a disease that is characterised by the swelling of the gall bladder (Theodore M. Bayless, Anna Diehl, 2005). I would therefore need to conduct a n assessment of the patient’s gall bladder to monitor if there are swelling on it. In addition, I would find out from the patient if he had ever had any gallbladder complications in the past. In completing the patient’s admission assessment, I would invite a care giver to be a witness since the daughter who had accompanied the patient was a child (NANDA International, 2014). I would inquire about the history patient’s current illness and past medical history. I would also be interested in knowing the kind of medications that have been administered to the patient, the patient’s immunisation status as well as his family history. There are additional requirements which had not been taken by the first nurse that would have to be taken. Such measurements include weight of the patient during admission, height and respiratory rate. I would also asses the working of the patient’s body organs, particularly the gall bladder whose malfunction is commonly associated with the condition (Ronnie A. Rosenthal, Michael E. Zenilman, Mark R. , 2001). These focussed health assessment would need to be conducted because they help in determining the next course of action to be taken on the patient. A person who is not suffering from the condition would be much healthy. He or she would not be suffering from the kinds of pains that the patient is complaining of. At the same time, there will be no cases of vomiting and fever. A person’s skin colour would also not be pale yellow, but dark reddish, an indication that the person has sufficient body fluid (Soumitra R. Eachempati, R. Lawrence Reed, II, 2015).
Detail of the assessment
I would first invite health care giver into the room where I would assess the patient. The healthcare provider would act as a witness during the entire process. I would also welcome the daughter to be in our company since she is the one who had come alongside the father, even though she is underage. I would then introduce myself to the patient and also explain to him all the assessments that I would carry out. I would also explain the reason why such assessment was necessary (Wilson S.F, 2012). There are a number of assessments that had not been carried out by the first nurse. I would therefore move on and carry the out. I would inquire about the patient’s current and past medical history. Another information that I would inquire is the patient’s family history so that I would be able to reach out to them if need arises (WeberJanet R. , Kelley Jane, 2013). Finally, I would take measurements such as weight, height, heart rate. There are instruments designed for taking the measurements so there would be no problem. However, it would be necessary to confirm some of the information given by the patient. I would interview the daughter separately to conform the information that would have been provided by the father in regard to their family history as well as the father’s current medical history. Since the two stay together, the daughter may have additional information that the father may fail to present given his deteriorated medical situation. I would also inquire from the patient about the kinds of medicines that had been administered to him prior to the visit. Finally, I would safe guard the confidentiality of all the information that the patient and the daughter would have shared with me ( DeWit S.C, O’Neill P.A, 2013).
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