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 1Case 2Case 3Subjective 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 analyzing a case study of a patient and discussing various aspects related to their health. We will explore the socioeconomic, spiritual, lifestyle, and other cultural factors that can influence the health of the patient. Additionally, we will discuss the SOAP 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 nurses must be aware of in order to assess specific functions.
The specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient in Case 1 can be analyzed as follows:
Socioeconomic Factors: The patient in Case 1 is an 86-year-old Asian male who is physically and financially dependent on his daughter, a single mother. The financial limitations and lack of resources can impact the patient’s access to healthcare services and preventive measures. Additionally, the patient’s dependence on his daughter for physical support may also limit his ability to independently manage his health conditions.
Spiritual Factors: The patient in Case 1 expresses concerns about his lifestyle impacting his chances of getting into Heaven. These spiritual beliefs and fears can influence his mental well-being and overall health. Understanding the patient’s spiritual beliefs is crucial to providing holistic care and addressing any anxieties or distress related to them.
Lifestyle Factors: The patient in Case1 has a history of chronic prostatitis and has been smoking “pot” and using alcohol. These lifestyle factors, including substance use, can have significant implications for the patient’s physical and mental health. Assessing the extent and impact of these lifestyle choices is essential for developing an appropriate care plan.
Cultural Factors: Being aware of the patient’s cultural background, specifically their Asian heritage, helps healthcare providers understand any cultural norms, values, or practices that may impact their health choices and decision-making. This knowledge can ensure culturally sensitive and competent care delivery.
The SOAP approach is a commonly used method for documenting patient data and is an acronym for Subjective, Objective, Assessment, and Planning. Each component serves a specific purpose in the documentation process:
1. Subjective: This refers to the subjective information provided by the patient or their caregiver. It includes the patient’s complaints, symptoms, medical history, social history, and other relevant information gathered through direct questioning or interviews. This information is primarily based on the patient’s verbal accounts and perceptions.
2. Objective: The objective component includes measurable and observable data obtained through physical examination, diagnostic tests, and laboratory reports. This data is factual and focuses on the findings that can be observed or measured, such as vital signs, physical appearance, laboratory results, and imaging results.
3. Assessment: The assessment is a clinical judgment or diagnosis made by the healthcare provider based on the subjective and objective data. It involves analyzing and interpreting the collected information to identify the patient’s health problems, their severity, and related factors. The assessment also includes identifying any potential risks or complications.
4. Planning: The planning component involves developing a comprehensive care plan based on the assessment findings. It includes setting goals, establishing priorities, and determining interventions or treatments to address the identified health problems. The care plan should be individualized, evidence-based, and consider the patient’s preferences, cultural beliefs, and resources.
The functional anatomy and physiology of a psychiatric mental health patient involve various key concepts that nurses must know to assess specific functions. Some of these key concepts include:
1. Neurotransmission: Understanding the role of neurotransmitters in mental health is crucial. Imbalances in neurotransmitters, such as serotonin, dopamine, and norepinephrine, can contribute to mental health disorders like anxiety, depression, or schizophrenia.
2. Brain Structures: Knowledge of different brain structures allows nurses to assess functions related to mental health. Areas such as the prefrontal cortex, amygdala, and hippocampus are involved in emotional regulation, memory, decision-making, and other cognitive processes.
3. Psychopathology: Familiarity with various mental health disorders, their diagnostic criteria, and symptomatology is essential for recognizing and assessing specific functions. This includes understanding the signs and symptoms of mood disorders, anxiety disorders, personality disorders, psychotic disorders, and others.
4. Cognitive Functioning: Assessing cognitive functions like attention, memory, executive function, and language skills is crucial when evaluating mental health patients. This helps identify any deficits or abnormalities that may be indicative of cognitive impairment or neurocognitive disorders.
5. Psychosocial Factors: Recognizing the influence of psychosocial factors, such as social support, family dynamics, socioeconomic status, and stressors, helps nurses understand the contextual and environmental factors impacting a patient’s mental health.
By having a solid understanding of the functional anatomy and physiology of psychiatric mental health patients, nurses can perform comprehensive assessments and provide individualized care tailored to the unique needs of their patients.
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