Description
Response to Peers Case 1:
76-year-old Black/African-American male with disabilities living in an urban setting.
What are the barriers to interpersonal communication?
There are various barriers to effective interpersonal communication, including language. Although the patient is African American, English is not their first language thus might become complex and confusing. Psychological barriers to interpersonal communication include embarrassment, cognition issues, and mental disability. The patient may feel uncomfortable in communicating how they feel and low assertiveness and confidence. Besides, considering the psychological barriers, the patient may have stress or anxiety or hearing defects which may significantly hinder effective interpersonal communication (Mitchel et al., 2017). Cultural medical mistrust is also a barrier. African-Americans have a history of unequal health care treatment due to their ethnicity. The patient might thus find it difficult to express how they feel due to the fear of stereotyping. African Americans develop a reluctance to trust most healthcare providers outside their ethnic community due to historical and contemporary racism and oppression experiences (Mitchel et al., 2017). Besides, the cultural beliefs of the patient may differ, affecting interpersonal communication. A misunderstanding of the patient’s cultural beliefs will affect the ability of the patient to give information.
What are the procedures and examination techniques that will be used during the physical exam of your patient?
The procedure for care involves first explaining to the patient what I will be doing and showing him the equipment that I will use and the equipment’s purpose. Demonstration of the procedures to a family member is also essential for understanding if the patient has mental disabilities. Building trust is vital in providing patient-centered care. Besides, identifying accommodations and modifications as appropriate for engaging the patient in complete health history and assessment.
Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
Subjective, Objective, Assessment, Planning (S.O.A.P.) is an approach for healthcare professionals’ documentation. S.O.A.P provides essential information about the patient’s health status and communication between the healthcare providers. The documentation thus serves as a cognitive aid for retrieving information and learning about the patient based on the record (Lenert, 2017). Subjective data is based on personal views, experiences, and patient emotions. The subjective data includes the chief complaint, which can be a condition or the reason the patient presents. Subjective data also includes patient illness history, medical and family history, and system review (Lenert, 2017). Objective data contains information based on the patient encounter. The objective data includes physical examination data, laboratory results, vital signs, and other diagnostic data. On the other hand, assessment involves the synthesis of the subjective and objective data to come up with a diagnosis. The assessment elements include the problem, differential diagnosis, and the pre-existing diagnosis. The plan section entails the testing and consultation with other healthcare providers in addressing the patient’s problem. The plan also entails the steps taken for the treatment of the patient. The treatment plan entails the testing needed and the rationale for each test, therapeutic medication, referrals, patient education, and counseling (Lenert, 2017). The plan section is essential for addressing any future issues. A comprehensive SOAP contains all the subject and objective data and effectively assesses the data to create a patient-centered assessment and care plan.
Response to Peers Case Studies 2
Case Study 2: 55-year-old Asian female; Question 1: Interpersonal communication is vital in health assessment and planning for patient treatment. Interviewing patients from different cultures is associated with barriers that may hinder the interpersonal communication. A great percentage of Asians believe in interpersonal relationships and family ties. Due to their cultural preferences and values, the patient may be unwilling to express her emotions and feelings during examination. The patient may be reluctant in expressing and discussing her problem thus posing a great barrier to interpersonal communication and the interview process (Khosla et al., 2017).
Due to strong believe in family ties, the patient may be unwilling and reluctant in opening up and responding to my interview questions. This can also be caused by fear not to impact negatively on her family. Before providing any information concerning their health and treatment, Asians consult family members (Khosla et al., 2017). Therefore, examining the client in absence of her family members may be a great barrier to our relationship.
Asians put a lot of value on group consensus especially when making key decisions concerning their health. The Asian culture prefers that a female patient be examined by a female doctor or practitioner. Therefore, health provider preference depending on gender is a potential barrier to interpersonal communication. Additionally, language barrier is likely to occur when interviewing the Asian patient (Khosla et al., 2017).
Case Study 2: Pre-school age white female; Question 1: When interviewing and examining a pre-school aged patient, the likely barriers to interpersonal communication include fear, lack of confidence, lack of trust, lack of autonomy, lack of knowledge about certain aspects and inability to make decisions. When dealing with a child, the provider must engage her parent or guardian as a key informant to obtain detailed information. A child is less likely to respond to interview questions as expected. Additionally, it may be challenging to establish a good rapport and therapeutic relationship with a child due to fear, lack of trust, and lack of confidence to face the provider.
Procedures and examination techniques used during the physical exam of your patient
The examination techniques that can be applied during the physical examination of both patients are inspection, percussion, palpation, auscultation, manipulation, and mensuration. Inspection is used to check the outward body appearance including shape, skin color, consistency, neck veins, swelling on joints, and abdomen. Palpation enhances the identification of lumps and masses in the body. Percussion is used to determine masses and fluid-filled lumps based on the sound produced on tapping. Auscultation is carried out using a stethoscope and enhances the identification of abnormal sounds in the lungs and heart (Jarvis, 2018).
Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
SOAP note is a one of the highly structured formats used by healthcare providers to document patient data. Subjective data consists of the information provided by the patient concerning his or her problem or intervention. Objective data refers to the providers or therapists observations and the implemented treatment interventions. Assessment data consists of the provider analysis of the different components of the patients comprehensive health assessment. Planning focuses on the treatment plan to be implemented in relation to the established goals and objectives of care. Planning integrates both pharmacological and non-pharmacological treatment approaches and interventions that are effective in addressing the patients primary problem (Jarvis, 2018).
Submission Instructions
- You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts.
- All replies must be constructive and use literature where possible. Bibliography use should be from 2016-2021
