NUR504- REPLY TO BEJAMIN

Case 3

• 16-year-old white pregnant teenager living in an inner-city neighborhood.

What are the barriers to interpersonal communication?

As a clinician, interpersonal communication barriers when dealing with a 16-year-old white pregnant teenager are many. They include fatigue, anxiety and embarrassment, age difference between clinician and patient, and the patient’s values and beliefs (Bosworth, 2010). For one, pregnant adolescent patients might have a problem concentrating due to fatigue. Thus, gathering information from such a patient might be a difficult task for any clinician. When patients are not entirely concentrated on giving the correct information, accurately diagnosing and treating them will be a huge ask. Adolescent patients tend to be anxious or embarrassed about their condition, especially if it is an unplanned pregnancy. No one would feel comfortable getting undressed in front of a stranger, much less a teenage mom-to-be. Thus, anticipating embarrassment and finding a way to minimize it can help ease an uncomfortable situation.

Also, everyone has their assumptions based on their culture or beliefs. A 16-year-old white pregnant teenager can genuinely believe that only a female nurse can attend to her and that men would not do a thorough job. The clinician should consider such assumptions before attending to the patient. This goes hand in hand with those adolescent patients who believe that junior staff can properly treat them. The age difference between the clinician and the patient can sometimes be an issue, especially if the patient feels she will not communicate comfortably with an older attendant. Lastly, a 16-year-old white pregnant teenager is most likely to be anxious or embarrassed about her condition. Teenagers may be hesitant to openly discuss their condition in the present of a parent, and my also feel guilty and worried about what their peers might think of them. Thus, the privacy and confidentiality of this interaction will be of utmost importance.

What are the procedures and examination techniques that will be used during the physical exam of your patient?

The 16-year-old white pregnant teenager will be taken through a geriatric assessment. However, since teenagers may hesitate to talk freely in the presence of their parent, the clinician should ask for permission on the patient’s behalf for the parents to be absent while the interview is being conducted. Also, the clinician should avoid any painful or intrusive procedures and do as much as possible with the patient still dressed and seated. The patient should also be asked if they prefer certain things done and whether there are specific movements they feel uncomfortable doing. For this patient, the first step will be to arrange for privacy, quiet, and any special needs since the physical examination will be affected by the environment’s quality. It will also be essential to make sure the patient is calm, relaxed, and adequately draped or gowned. The next step will be to conduct a general inspection and check for vital signs, and an eye and ear examination will follow this. An ophthalmo-otoscopy will then be undertaken before connecting the otoscope to the nasal speculum and examining the nares. A mouth examination will then follow before evaluating the face to examine symmetry and other details concerning motor divisions of the V and VI cranial nerves. For a young mother, a complete examination may be easier if it is divided into multiple sessions rather than taking the patient through hours of exhaustive tasks. The procedure will yield a more relevant and complete list of psychosocial issues, functional problems, or medical problems. Results will be thoughtfully integrated with the patient’s pathophysiology and history (Ball et al., 2015).

Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.

The Subjective, Objective, Assessment, and Plan (SOAP) is an acronym used in nursing to document patient’s data in a structured way. It provides clinicians with a framework for evaluating patients’ information. Also, it offers a cognitive outline that aids in clinical reasoning. Using the framework, nurses are able to assess, diagnose, and treat patients in an informed and reasoned manner. This paper aims to discuss S.O.A.P. approach in documenting patients’ data.

The subjective (S) stands for the patent’s experiences, personal views, and feelings. The component included here is chief complaint (CC), history of present illness (H.P.I.), and review of systems (R.O.S.). The patient chief complaint is a short statement of the patient purpose to visit the hospital. History of present illness describes the patient current situation or condition since the time that the symptoms for the disease started showing. It describes the condition in a narrative form. The review of systems compiles the pertinent and negative symptoms (Jenkins &David, 2019).

The Objective assessment (O) entails the documentation of information that the clinician observes from the current patients’ condition. This documentation covers vital signs, physical evaluation findings, imaging results, laboratory information, and other diagnostics data. Simultaneously, the assessment section entails the synthesis of evidence documented in the ‘subjective’ and ‘objective’ sections. This section records the assessment of the patient’s situation, how the problem behaves, and any changes in the condition. It is at this stage that the decision-making process is discussed in more in-depth details (Jenkins & David, 2019). Lastly, the plan (P) section documents what is supposed to address the patient’s concerns. This includes things like doing ordering referrals, additional testing, and consultations with other health care providers. Also, it documents the goals therapy, drugs, and procedures performed on the patient (Jenkins & David, 2019).

Reference

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination . St. Louis, MO.

Bosworth, H. (Ed.). (2010). Improving patient treatment adherence: A clinician’s guide. Springer Science & Business Media.

Jenkins, M. L., & Davis, A. (2019). Transforming Nursing Documentation. Studies in health technology and informatics, 264, 625-628.