NUR 418 STU Physical Examination and Health Assessment Discussion Responses

Description

respond to at least two of your peers 
Discussion #1
Interviewing a patient is one of the most essential tasks a nurse must complete. Conducting and successfully completing a patient interview will provide the nurse with vital information about a patient’s current and past condition. The interview process has several goals. The first goal is to gather data; this is where nurses will ask questions and obtain data from the patient’s responses and behavior. Another goal is for the nurse to establish trust and build rapport, allowing the patient to open up and share sensitive and personal information. The interview process also allows nurses the opportunity to teach patients about different conditions, as well as about things they can change or implement for health promotion and disease prevention (Jarvis & Ann, 2020).
        During the interview, nurses will collect information from the patient to formulate the patient’s history. The history has several components and they include the chief complaint, the history of present illness, past medical history, family history, social history, and review of systems. The chief complaint is the health concern that brought the patient to seek care. The history of the present illness is a detailed description of the chief complaint and its progression. Past medical history summarizes how the patient has been prior to this medical encounter, and it can include diseases, surgeries, medications, and allergies. Family history is important, as it can provide nurses with information that allows them to detect hereditary diseases and health risks (Pessanha et al., 2022). The social history of the patient is essential to determine the conditions in which the patient lives. It includes the patient’s socioeconomic status, occupation, marital status, living situation, and the possible use of drugs, and alcohol and tobacco consumption. All these details can help determine if the patient may need help from any programs, to achieve maximum recovery when outside the medical facility. Last but not least is the review of systems. This is when the nurse asks questions that cover all organ systems to help find signs and symptoms that will help formulate a diagnosis.
         There are many challenges when obtaining information from patients. It can be verbal information or objective information such as vitals. When I started my first nursing job, there was a time when I almost made a medical error. I remember I was taking a patient’s blood pressure, and I was getting an elevated reading of 160/90. After I took the measurement a few times to make sure it was accurate, I went to get medication to lower the patient’s blood pressure, and on my way back, I decided to go look at the cuff that I was using to take the patient’s blood pressure and I was using a small adult cuff instead of the regular size. When I changed the cuff, I remember getting a reading that was in the 130s over 80s. From that incident I learned that I should always make sure I am using the appropriate equipment when caring for a patient. I also struggled several times to communicate with a few of my patients that were from different cultures than myself due to the language they spoke, and their understanding and trust of Western medicine.
Discussion #2
What are the goals of a patient interview?
An interview with a patient is conducted so that medical professionals may learn more about the patient’s past and present health conditions, habits, and treatment options. The interview between the doctor and patient also helps establish a sense of mutual respect and trust. The patient has an outlet for expressing their thoughts and worries, and the doctor better understands how to meet those needs when a therapeutic connection is established between them (Jarvis, 2019). As a result of the information gleaned from the patient interview, the healthcare professional is better equipped to create a treatment plan tailored to the patient’s specific requirements.
Name and describe each component of the Patient’s History (Chief Complaint, History of Present Illness, etc.)
Chief complaint: This is the primary reason the patient has seen a doctor. Often the first item recorded in a patient’s history, the chief complaint, is a brief statement outlining the patient’s symptoms or condition.
History of Present Illness: This section of the patient’s history describes the patient’s current health issues (Chetty, 2016). It contains information on the onset, duration, and intensity of symptoms and the patient’s response to therapy.
Medications: Current medicines, including supplements or OTC meds, are documented here as part of the patient’s medical history.
Describe an incident where you had used improper technique in measuring blood pressure; what did you learn from that incident?
There was once an occasion when I incorrectly measured a patient’s blood pressure. I didn’t know where the cuff should go, so I positioned it excessively high on the patient’s arm. I had to start again since the results were so wildly off-the-wall. This experience taught me the importance of properly taking a patient’s blood pressure. The appropriate placement of the cuff is at the level of the heart, with the bottom border of the cuff approximately 2 cm above the bend of the elbow. I also learned the importance of using the correct cuff size for the patient’s arm since this might result in inaccurate results. After that, I always double-checked the cuff’s size and position before measuring a patient’s blood pressure. In addition, I realized the need to maintain the correct technique to get reliable results since doing otherwise might have dire consequences for the health of the patient and the effectiveness of the therapy they receive.
Describe a barrier when assessing a patient from a different culture.
When evaluating a patient from a foreign culture, I found that language was a hurdle. Although I could converse with the patient in English, it soon became clear that they felt more at ease and expressed themselves more precisely when using their native language. Despite having access to a translator, subtleties still needed to be recovered in translation. There was also a noticeable linguistic and cultural divide. Understanding the patient’s mental and physical health perspectives was challenging since I needed to share their worldview and conventions. I could gauge neither their intelligence nor their ability to care for themselves with any degree of precision. In addition, I could not provide the best possible treatment for the patient since I did not understand their cultural norms and traditions. The patient’s and my mutual lack of cultural competence severely hampered our ability to provide effective treatment. I could not provide an accurate diagnosis or appropriate care for this patient because I was unaware of his or her cultural background. I had to put forth the additional effort to learn about the patient’s culture and empathize with the patient’s worldview. Because of this, I could provide each patient with individualized attention.

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