Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, & Documentation Strategies

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.

Case 1
76-year-old Black/African-American male with disabilities living in an urban setting.
Adolescent Hispanic/Latino boy living in a middle-class suburb

answer the following questions:

What are the barriers to interpersonal communication?
What are the procedures and examination techniques that will be used during the physical exam of your patient?
Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.

Submission Instructions:

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

Answer

Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, & Documentation Strategies

Patient assessment is important in healthcare. Good communication is also important to ensure a concrete understanding between patients and healthcare providers. SOAP is an assessment strategy widely used in healthcare to ensure quality patient assessment and management. This essay focuses on assessing a 76-year-old African American male and barriers to interpersonal communication.

Communicating with elderly patients can be challenging due to their declining physical, cognitive, and sensory abilities. Older adults have hearing (presbycusis) and comprehension problems, affecting about a third of adults of age 61-70 years (Guttman et al., 2019). They have cognitive problems such as memory loss leading to ineffective communication (Guttman et al., 2019). They cannot provide complete health histories, and sometimes they are unreliable historians. They also have visual problems. Other barriers to interpersonal communication may include emotional incongruence and racial discrimination.

Physical examinations entail various examination techniques, including inspection, palpation, auscultation, and percussion. Auscultation is done before percussion in the gastrointestinal system to avoid distorting the bowel sounds (Egilsdottir et al., 2019). The inspection involves observing the various organs and organ systems for abnormalities without intervening. For this patient, observing the skin and visible structures such as teeth, throat, jugular veins, conjunctiva, and lips. Inspections allow the detection of obvious signs of disease or injury. Palpation is an important technique in understanding the characteristics of organs or closed injuries. Palpation entails pressing an organ above the skin with the middle parts of the fingers. Palpation investigates characteristics such as the size of organs, swellings, tenderness, and pulse (Egilsdottir et al., 2019).

Percussion is the application of light force directly or indirectly on the skin surface to elicit sound used to describe the internal organs. Percussion is used to investigate organ sizes and differentiate water, air, and solid compartments. Specific sounds are elicited on auscultation of specific organs, and changes could indicate pathologies. Auscultation is a physical exam technique that studies the different sounds produced by various body organs. The most widely studied sounds are bowels, respiratory, and heart sounds. Abnormal sounds include hyperactive and absent bowel sounds, crackles, wheezes, stridor, murmur, and gallops (Egilsdottir et al., 2019). These physical assessment techniques provide information used to diagnose and manage patient conditions.

SOAP is a systematic data collection and analysis method for assessing patients, diagnosing, and preparing a care plan. The components, subjective, objective, assessment, and plan, are filled in chronological order (Podder et al., 2021). The approach begins with subjective data. Subjective data is collected from the patient’s verbal report and includes chief complaints, history of illness, past medical history, socio-economic history, family history, and the review of systems. Objective data is data collected by the nurse or the care provider assessing the patient. It includes results from physical examination and adjutant tests such as laboratory and radiological tests(Podder et al., 2021). These tests may be ordered to aid in a definitive diagnosis. In some instances, a focused physical assessment is done when the signs and symptoms are focused on one system, such as the respiratory system. The next component, assessment, involves determining the various patient problems. It involves diagnosing and considering alternative views and differentials. The last component, plan, entails the management of the patient based on the assessment diagnosis.

Barriers to interpersonal communication can be attributed to declining functional ability among the elderly. The age gap also contributes to communication barriers. The physical examination strategies are inspection, percussion, palpation, and percussion, and they all provide important information for patient diagnosis and management. The SOAP assessment strategy utilizes assessment cues in chronological order leading to quality care delivery.

References

Egilsdottir, H. Ö., Byermoen, K. R., Moen, A., & Eide, H. (2019). Revitalizing physical assessment in undergraduate nursing education-what skills are important to learn, and how are these skills applied during clinical rotation? A cohort study. BMC Nursing, 18(1), 1-11. https://doi.org/10.1186/s12912-019-0364-9

Guttman, O. T., Lazzara, E. H., Keebler, J. R., Webster, K. L., Gisick, L. M., & Baker, A. L. (2021). Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. Journal of Patient Safety, 17(8), e1465-e1471. https://doi.org/10.1097/PTS.0000000000000541

Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP notes. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482263/

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