Reflective Journal: Chronic disease management

Reflective Journal

Chronic disease management

We use care plan meeting to collaborate with patient and family. This is done by the IDT- interdisciplinary team. This has Nurse, dietician, recreation, pharmacy, MD, and social work. We talk about their drug regime and see if pharmacy can continue what they have been taking. We assess also how much the patient or the family understands the medication and why they are taking it.

A lot of time we know that these patients may go through a culture shock transitioning from the hospital to the rehab facility. So aim to answer all the questions to make them as comfortable as we can. Keeping into account the different rules and regulation that are in place for the nursing home compare to other facilities. CMS/DOH.

We work together and coordinate the care plan because it allow all those who are involved with the patient to be on the same page and it gives that patient care center. It allows everyone to address the needs of the patient. In the facility we drain the Pleurex catheter in the morning for everyone, however, this patient requests in the evening because they sometimes get tired and exhausted depending on the amount that has been drawn out. We agree to do that resident draw in the evening as per their request because it is all about the patient and the need to help them rehab and return home.

ABOVE IS WHAT WE SPOKE ABOUT. PLEASE EDIT. i HAVE ATTACH THE DOCUMENT THAT CORRELATE WITH THE JOURNAL IF YOU WOULD LIKE TO MAKE THE JOURNAL FLOW WITH IDEAS FROM IT ALSO