Diversity and Health Assessments
Case 1
Subjective Data
CC: "Annual physical exam"
History of Present Illness (HPI): 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.
Drug Hx:
Current medication - denied
Allergies: no allergies to food or medications.
Family history: is very positive for diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General: no recent weight gains of losses, fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT):
Neck:
Respiratory:
CV: no chest discomfort or palpitations
GI:
GU:
Integument: history of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
Psych:
Objective Data
PE: B/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.
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, ornasopharynx clear, poor dentition – multiple carries.
Lungs: CTA AP&L
Cor: S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XII
To prepare:
•Reflect on your experiences as a nurse and on the information provided in this week’s Learning Resources on diversity issues in health assessments.
•Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
•Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
•Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?
Post 1 page on
:
an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient above . Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history a.
Diversity and Health AssessmentsCase 1Subjective Dat.docx
1. Diversity and Health Assessments
Case 1
Subjective Data
CC: "Annual physical exam"
History of Present Illness (HPI): 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.
Drug Hx:
Current medication - denied
2. Allergies: no allergies to food or medications.
Family history: is very positive for diabetes, hypertension, and
alcoholism.
Review of Systems (ROS)
General: no recent weight gains of losses, fatigue, fever or
chills.
Head, eyes, ears, nose & throat (HEENT):
Neck:
3. Respiratory:
CV: no chest discomfort or palpitations
GI:
GU:
Integument: history of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in
memory or thinking patterns; no twitches or abnormal
movements
Psych:
4. Objective Data
PE: B/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.
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera
with mild icterus, nares patent, ornasopharynx clear, poor
dentition – multiple carries.
Lungs: CTA AP&L
5. Cor: S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm
below the costal margin.
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XII
To prepare:
6. •Reflect on your experiences as a nurse and on the information
provided in this week’s Learning Resources on diversity issues
in health assessments.
•Reflect on the specific socioeconomic, spiritual, lifestyle, and
other cultural factors related to the health of the patient you
selected.
•Consider how you would build a health history for the patient.
What questions would you ask, and how would you frame them
to be sensitive to the patient’s background, lifestyle, and
culture? Develop five targeted questions you would ask the
patient to build his or her health history and to assess his or her
health risks.
•Think about the challenges associated with communicating
with patients from a variety of specific populations. What
strategies can you as a nurse employ to be sensitive to different
cultural factors while gathering the pertinent information?
7. Post 1 page on
:
an explanation of the specific socioeconomic, spiritual,
lifestyle, and other cultural factors associated with the patient
above . Explain the issues that you would need to be sensitive to
when interacting with the patient, and why. Provide at least five
targeted questions you would ask the patient to build his or her
health history and to assess his or her health risks. And provide
3 current related references .
Reference
Readings
•Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015). Seidel's guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby. ◦Chapter 2, “Cultural
Competency” (pp. 21–29)
•Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced
health assessment and clinical diagnosis in primary care (5th
ed.). St. Louis, MO: Elsevier Mosby. ◦Chapter 1, “Clinical
Reasoning, Differential Diagnosis, Evidence-Based Practice,
and Symptom Analysis”
•Sullivan , D. D. (2012). Guide to clinical documentation (2nd
8. ed.). Philadelphia, PA: F. A. Davis. ◦Chapter 2, "The
Comprehensive History and Physical Exam" (pp. 19–36)
◦Appendices A–E (pp. 225–236
•Shaw, S. J., Huebner, C., Armin, J., Orzech, K., & Vivian, J.
(2009). The role of culture in health literacy and chronic disease
screening and management. Journal of Immigrant & Minority
Health, 11(6), 460–467.
Retrieved from the Walden Library databases.
