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

Sample Answer

While interviewing a pregnant 16-year-old white teenager living in an inner city it is important for a nurse to develop a rapport with the teenage girl which in turn will make the communication between them effective. However, this communication might be hindered by certain factors that can either be from the patient or from the nurse. The teenage girl might be nervous, afraid and experiencing feelings of shame.

This can be made worse by the fact that she is a minor and is most likely to be in company of a parent or caregiver. She might not be open for fear of judgement making it hard to communicate effectively with her(McLaughlin et al., 2019). The interviewing nurse on the other hand might not have enough knowledge and experience with interviewing girls with teenage pregnancies

The transgender man might also withhold a lot of information for fear of discrimination and judgment’s patient might also be uneasy or uncooperative in cases where by the pronoun used to address him is not that which he prefers. Just like in the case of the teenage girl, the nurse might not have enough experience interviewing transgender people and might also be having different cultural and social believes affecting the retrieval of information.

An obstetric examination should be done on the teenager. This includes determining the fundal height, the lie of the fetus and the presenting part which will be examined by the Leopold’s maneuvers(Celik & Ergin, 2020). The nurse should also auscultate for the fetal heart rate. External pelvimetry should be used to assess the bony pelvis and a bimanual vaginal examination and cervical examination which checks for any discharge and malformations that can hinder delivery.

Physical examination of the trans gender man should involve a pap smear where the provider will rule out cervical cancer after collecting histological samples. A thorough pelvic exam should also be done to rule out other Genito urinary abnormalities. A breast examination to rule out any lumps or axillary lymphadenopathy will also come in handy to rule out breast cancer(Iwamoto et al., 2021).

History taking is vital part in patient management. It entails collection of both subjective and objective data and from this data collected a healthcare professional can make a plan of management. Subjective data is usually obtained from the patient or those accompanying them and includes the patients’ chief complains and the history of presenting illnesses where the patients give a detailed chronology of their chief complains(Socrates et al., 2023).

A past medical and surgical history is also part of the subjective data to be collected. Family and socio-economic history where a patient gives details of their family members and any history. of chronic illnesses is crucial. Social history details any activities that can predispose the patient to certain diseases. Objective data on the other hand details the findings a healthcare professional makes on physical examination which entails inspection, palpation, percussion and auscultation(Socrates et al., 2023).

It also entails measurement of vital signs that are taken during examination. Assessment refers to the practitioners’ judgement from the data obtained from the patient. At this stage one comes up with a diagnosis and differential diagnosis. From the details obtained from subjective data, objective data and assessment, a patients care plan is made which entails both pharmacological and non-pharmacological interventions such as counselling, nutritional support, patient education and physical exercise. Laboratory investigations and radiological tests are also included here.

References.

• Celik, M., & Ergin, A. (2020). The effect on pregnant women’s prenatal attachment of a nursing practice using the first and second Leopold’s maneuvers. Japan Journal of Nursing Science JJNS, 17(2), e12297. https //doi.org/10.1111/jjns.12297
• Iwamoto, S. J., Grimstad, F., Irwig, M. S., & Rothman, M. S. (2021). Routine Screening for Transgender and Gender Diverse Adults Taking Gender-Affirming Hormone Therapy A Narrative Review. Journal of General Internal Medicine, 36(5), 1380–1389. https //doi.org/10.1007/s11606-021-06634-7
• McLaughlin, C. A., Gordon, K., Hoag, J., Ranney, L., Terwilliger, N. B., Ureda, T., & Rodgers, C. (2019). Factors Affecting Adolescents’ Willingness to Communicate Symptoms During Cancer Treatment A Systematic Review from the Children’s Oncology Group. Journal of Adolescent and Young Adult Oncology, 8(2), 105–113. https //doi.org/10.1089/jayao.2018.0111
• Socrates, V., Gilson, A., Lopez, K., Chi, L., Taylor, R. A., & Chartash, D. (2023). Predicting relations between SOAP note sections The value of incorporating a clinical information model. Journal of Biomedical Informatics, 141, 104360. https //doi.org/10.1016/j.jbi.2023.104360