Response to paez

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Case # 2. 
 “55-year-old Asian female living in a high-density poverty housing complex. Pre-school-aged white female living in a rural community”

Interpersonal Communication Barriers.

 Communicational flow and the capability of establishing interpersonal links in any interview gets influenced by numerous factors, such as the medical client’s age, norms, family status, social status, or cultural beliefs. In the selected case of patient scenarios, a critical barrier to effective interpersonal communication may be a lack of transparency and trust problems. Communication becomes problematic when the medical practitioner and their client endure trust problems. This challenge may lead the patient in the selected case to fail to open up to share the required details pertinent to their clinical care, which is also needed to properly comprehend the patient’s scenario and plan for their intervention. To a few, trust and transparency issues can make patients anxious and fail to provide the needed vital information for their treatment, goal setting, and care plan (Alshammari et al., 2019).

 The next barricade towards effective interpersonal communication is the lack of emotional safety and security, particularly on the patient’s side. This problem makes the medical client feel discomfort, particularly when sharing their ideas and feeling, expressing their health problem, and becoming authentic owing to their fear of facing criticism, ridicule, or being turned off. Being insecure emotionally triggers immense fear in the client, obstructing them from effective interpersonal communication and creating effective interpersonal linkage (Blair & Smith, 2012).

 The communication style during the clinical interview phase can be a vital barrier to establishing effective interpersonal communication. At times, the client and the clinical profession can have diverse communication approaches (Alshammari et al., 2019). For example, when either the patient or the clinician prefers to pursue indirect communication while the other part opts for direct communication. Also, some medical clients might opt for details info which can create a barrier to interpersonal communication whenever the clinician is not in a position to offer them. Hence, medical professionals might fail to understand their patients due to the communication approach. 

  Lastly, the poor clinical setting for the assessment and noise the maybe another barrier affecting interpersonal communication. Any clinical assessment selects a substantial place and works toward techniques and mechanisms for practical and effective communication approaches (Kim & white, 2018). Declined management techniques and ignorance of the imminent issues or problems may diminish the confidence levels of the selected patient’s scenarios and the expected effectiveness in their communication (Blair & Smith, 2012). For instance, the high-densely poverty housing complex for the elderly patient is full of distractions, and the client might be unable to disclose every needed clinical detail regarding her health condition plus other challenges linked to their sickness.

Examination Approaches and Procedure to get Applied to Scenario #2

 I will use clinical examination approaches during the patient’s physical examination are inspection, palpation, percussion, and auscultation. During the inspection, in order to determine what is normal and what is abnormal, inspect each body system using the senses of sight, smell, and hearing. You need to examine the body system from head to toe to detect how they are colored, sized, located, moving, cool and hot, smelling, symmetrical, and hearing. I will thoroughly deliberate and visually observe the client’s behavior by checking the most vital issues, like changes in their body. To perform palpation, you will have to use varying degrees of pressure on different parts of your hand to touch the patient. It is very important to keep your fingernails short and to keep your hands warm as your hands are your tools. When performing palpations on mucous membranes or on areas in contact with body fluids, it is recommended to wear gloves. Tender areas should be palpated last.  Light palpation can be used to detect surface abnormalities by feeling for them with this technique. You should use light pressure when pressing the skin between 1/2 and 3/4 inches (about 1 and 2 cm) with your finger pads. You should evaluate the texture, tenderness, temperature, moisture, elasticity, pulsations, and masses. The most accurate way to determine the size, shape, tenderness, symmetry, and mobility of internal organs and masses is to feel them deeply through palpation. Use firm, deep pressure to depress the skin between 1 1/2 and 2 inches (about 4 to 5 cm). Apply firmer pressure if necessary by placing one hand over the other. Percussion entails using a quacking and sharp tapping of the clinician’s hands or fingers to produce sounds. It enables the profession to locate every underlying structure’s density, position, and site. A percussion identifies organ borders, identifies organ shape and position, and identifies whether an organ is solid or filled with fluid or gas by tapping your fingertips or hands quickly and sharply against parts of the patient’s body. Lastly, I will undertake auscultation by listening to or eliciting sounds in the heart, lungs, abdominal viscera, and blood vessels. In the abdomen, you have to auscultate before palpating because you can increase the motility of the intestines (Kohtz et al., 2017).

Patient Data Documentation (S.O.A.P. Approach)

In the S.O.A.P. method, the Subjective part entails the client’s experiences related to the client’s feelings, experiences, and viewpoints. The purpose of this part is mainly to integrate the client’s most important complaints, a history of ailment presentation, current medications, allergies, and the system’s history, as well as all-inclusive information about the client’s history (Briscoe & Harding, 2020). The Objective part of the approach encompasses details collected by the medical professional during their encounter with the client. The data includes vital signs, lab information, imaging results, and physical assessment discoveries. In another word, objective data refers to details that can get observed, felt, heard, or measured by a physician to record the patient’s condition or problem. (Kasamatsu et al., 2020). Assessment in the approach entails synthesizing the gathered personal and objective information to make the client diagnosis. Thus, this part states the client’s primary and probable differential diagnosis. The last part of the SOAP is the plan is what the health care provider will do to treat the patient’s concerns, such as ordering medications given and education provided. The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. Lastly, the planning part highlights measures needed to address the patient’s problem (Briscoe & Harding, 2020).

References

Alshammari, M., Duff, J., & Guilhermino, M. (2019). Barriers to nurse-patient communication in Saudi Arabia: an integrative review. B.M.C. nursing, 18(1), 1-10.

Briscoe, J., & Harding, T. (2020). Promoting the use of the soap (I.E.) documentation framework in medical nurses’ practice. Kai Tiaki Nursing Research, 11(1), 17-23.

Blair, W., & Smith, B. (2012). Nursing documentation: frameworks and barriers. Contemporary nurse, 41(2), 160-168.

Kim, B., & White, K. (2018). How can health professionals enhance interpersonal communication with adolescents and young adults to improve health care outcomes?: a systematic literature review. International Journal of Adolescence and Youth, 23(2), 198-218.

Kohtz, C., Brown, S. C., Williams, R., & O’Connor, P. A. (2017). Physical assessment techniques in nursing education: a replicated study. Journal of Nursing Education, 56(5), 287-291.

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