For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Case 1(NO)Case 2 (NO)Case 3 ( THIS is MY CASE)Subjective DataChief Complaint
(CC)“I came for my annual physical exam, but do not want to be a burden to my daughter.” “I am here for my annual physical exam and have been having vaginal discharge.” “Annual physical exam” History of Present Illness (HPI)At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.32-year-old Hispanic/Latina pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank.23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.PMHHypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis PSHS/P cholecystectomy Drug HxCurrent Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasionCurrent Meds: deniedAllergies No allergies to food or medications.Family HxShe has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0.He has a family history of diabetes, hypertension, and alcoholism.Review of Systems (ROS) General+ weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.No fatigue, fever, or chills.No recent weight gains of losses, fatigue, fever, or chills.Head, Eyes, Ears, Nose & Throat (HEENT)No changes in vision or hearing, no difficulty chewing or swallowing. NeckNo pain or injury No pain or injury Respiratory CV no chest discomfort or palpitationsGI GUno urinary hesitancy or change in urine stream Integumentmultiple bruises on his upper arms and back.multiple piercings, and tattoos. Old scars related to “cutting”history of eczema – not activeMS/Neuro+ falls x 2 within the last 6 months; no syncopal episodes or dizzinessno syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements.no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movementsObjective Data PEB/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6 General 23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress. HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. LungsCTA AP&LCTA AP&LCTA AP&LCardS1S2 without rub or gallopS1S2 without rub or gallopS1S2, +II/VI holosystolic murmur; without rub or gallopAbdbenign, normoactive bowel sounds x 4benign, normoactive bowel sounds x 4benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.GUexternal genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact. Extno cyanosis, clubbing or edemano cyanosis, clubbing or edemano cyanosis, clubbing or edemaIntegumentmultiple bruises in different stages of healing – on his upper arms and back.intact without lesions masses or rashes.intact without lesions masses or rashes.MS NeuroNo obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XII
Once you received your case number, answer the following questions:
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
- Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?
Expert Solution Preview
In this discussion, we will be focusing on Case 3, which involves a 23-year-old Native American male who is experiencing anxiety and has been using substances to cope. We will explore the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to this patient’s health. Additionally, we will discuss the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain its components. Lastly, we will delve into the functional anatomy and physiology of a psychiatric mental health patient, highlighting key concepts that a nurse must be aware of to assess specific functions.
The socioeconomic factors related to the health of our patient include financial dependence, as he is physically and financially dependent on his daughter. This may limit his access to healthcare and resources, affecting his overall health outcomes. Additionally, his daughter being a single mother with limited time and money may further compound the challenges of managing his health needs.
In terms of spiritual factors, the patient expresses concerns about not getting into Heaven if he continues with his current lifestyle. This spiritual belief may influence his decision-making regarding his substance use and help-seeking behavior.
Regarding lifestyle factors, the patient reports smoking marijuana and drinking alcohol as a means to cope with his anxiety. These drug use habits can have profound effects on his mental and physical health, exacerbating his anxiety symptoms.
The patient’s Native American heritage is also a cultural factor to consider. Understanding and respecting cultural beliefs and practices, such as traditional healing methods or community support systems, can help tailor the patient’s care to meet his unique cultural needs and enhance his overall well-being.
The S.O.A.P approach is a commonly used method for documenting patient data in healthcare. It consists of four components:
1. Subjective: This refers to the subjective information provided by the patient, including their chief complaint, history of present illness, past medical history, allergies, and review of systems. In our case, the patient provides information about his anxiety, substance use, medical history, and symptoms across various body systems.
2. Objective: This section involves the objective data collected through physical examination, laboratory tests, and diagnostic procedures. It includes vital signs, physical findings, and results of any relevant investigations. In our case, objective data includes the patient’s blood pressure, pulse rate, respiratory rate, temperature, height, weight, and BMI, as well as specific findings in each body system.
3. Assessment: This part involves the nurse or clinician’s assessment and interpretation of the subjective and objective data. It includes the clinician’s impressions, potential diagnoses or differential diagnoses, and identification of any potential issues or concerns. In our case, the assessment may include a potential diagnosis of anxiety disorder, potential substance misuse, and potential risks associated with the patient’s lifestyle choices.
4. Planning: This component outlines the plan of care based on the subjective, objective, and assessment data. It includes specific interventions, treatments, referrals, and educational needs identified to address the patient’s health concerns. In our case, the plan may involve referrals to a mental health professional, substance abuse treatment resources, and patient education on healthier coping strategies.
In order to assess the specific functions of a psychiatric mental health patient, nurses must have an understanding of the functional anatomy and physiology of the brain, as well as key concepts related to mental health. This includes knowledge of:
1. Neurotransmitters: Understanding the role of neurotransmitters, such as serotonin, dopamine, and norepinephrine, in regulating mood, cognition, and behavior is crucial. Dysregulation of these neurotransmitters can contribute to mental health disorders.
2. Stress response: The nurse needs to understand the body’s stress response, including the hypothalamic-pituitary-adrenal (HPA) axis. Chronic stress and dysregulation of the stress response system can contribute to the development or exacerbation of psychiatric disorders.
3. Cognitive functioning: Assessing cognitive functions, such as attention, memory, and executive functioning, is essential in understanding a patient’s baseline cognitive abilities and any potential cognitive impairments related to mental health conditions.
4. Psychosocial factors: Recognizing the impact of psychosocial factors, such as social support, coping mechanisms, socioeconomic status, and cultural influences, on mental health is crucial for a comprehensive assessment.
By having a strong foundation in these key concepts, nurses can effectively assess and identify any deviations from normal functioning, helping to guide appropriate interventions and treatment plans for psychiatric mental health patients.