Question

CRITICAL THINKING

1. Julie is a new patient who brings a list of her current medications to her first appointment. She indicates in her health history that she has several conditions for which she is taking medications prescribed by her previous physician, but she is unaware of which medication is associated with a particular condition. Her medical records have been requested from her previous physician, but have not yet arrived. What steps can you take to attempt to match her medications with the disorders that she reports?

2. Phil arrives at the medical office complaining of fatigue, weakness, and mild discomfort in the chest. He also reports that his weight has recently decreased and he has difficulty sleeping because he feels feverish at night. The physician requests that you perform tuberculin testing to determine whether Phil has a tuberculosis infection. What general steps do you follow to administer a Mantoux test and to interpret the results?

Answer 1

1) History taking and empathetic communication are two important aspects in successful physician-patient interaction. Gathering important information from the patient's medicalhistory is needed for effective clinical decision making while empathy is relevant for patient satisfaction.
Without an accurate medication history, prescribers may inadvertently make incorrect decisions about a patient's treatment, causing harm if previously discontinued medicines are restarted, or if current medicines are omitted or prescribed at the wrong dose for the patient. The medication reconciliation process is a shared responsibility of healthcare providers in collaboration with patients and families. It requires a team approach including nurses, pharmacists, physicians and other healthcare providers.
This process comprises five steps: (1) develop a list of current medications; (2) develop a list ofmedications to be prescribed; (3) compare themedications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.
Medication reconciliation is the process of comparing a patient's medication history with a list of medication orders. 2. Emergency nurses collect a Best Possible Medication History (BPMH), but do not perform medication reconciliation. The purpose of complete and accurate patient record documentation is to encourage quality, detail, and continuity of care.

2)
1)Locate and clean injection site 5–10 cm (2–4 inches) below elbow joint

-Place forearm palm-up on a firm, well-lit surface.

-Select an area free of barriers (e.g. scars, sores, veins) to placing and reading.

-Clean the area with an alcohol swab.

2)Prepare syringe

-Check expiry date on vial and ensure vial contains tuberculin PPD-S (5 TU/0.1 ml).

-Use a single-dose tuberculin syringe with a short (¼- to ½-inch) 27-gauge needle with a short bevel.

-Clean the top of the vial with a sterile swab.

-Fill the syringe with 0.1 ml tuberculin.

3) Inject tuberculin.

-Insert the needle slowly, bevel up, at an angle of 5–15°.

-Needle bevel should be visible just below skin surface.

4) Check injection site

-After injection, a flat intradermal wheal of 8–10 mm diameter should appear. If not, repeat the injection at a site at least 5 cm (2 inches) away from the original site.

5) Record information

-Record all the information required by your institution for documentation (e.g. date and time of test administration, injection site location, lot number of tuberculin).

READING:-
The results should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will probably need to be rescheduled for another TST.

1) Inspect site

-Visually inspect injection site under good light, and measure induration (thickening of the skin), not erythema (reddening of the skin).

2) Palpate induration

-Use fingertips to find margins of induration.

3) Mark induration

-Use fingertips as a guide for marking widest edges of induration across the forearm.

4) Measure diameter of induration using a clear flexible ruler

-Place “0” of ruler line on the inside left edge of the induration.

-Read ruler line on the inside right edge of the induration (use lower measurement if between two gradations on mm scale).

5) Record diameter of induration

-Do not record as “positive” or “negative”.

-Only record measurement in millimetres.

-If no induration, record as 0 mm.

Interpretation of TST depends on two factors:

–diameter of the induration;

–person's risk of being infected with TB and of progression to disease if infected.

Induration of diameter ≥5 mm is considered positive in:

–HIV-positive children;

–severely malnourished children (with clinical evidence of marasmus or kwashiorkor).

Induration of diameter ≥10 mm is considered positive in:

–all other children (whether or not they have received BCG vaccination).