Physical Examination and Health Assessment - Case Study Example

Health Assessment Documentation and Assessment Interview Summary Student Name: ___________________________________________ Lecturer: ___________________________________________ Student Id Number: ________________________________________ Class Number: ___________________________ Part 1: Health assessment documentation Philistine Houston has arthritis and takes her medication over the counter. She broke her arm when she was young and had a knee injury six months ago. She also developed cheek pox during her childhood. There was no record of pregnancy in her life. She was immunized with anti-tetanus when she was hospitalized with a broken arm. She attends health screens on annual basis for check-ups. No cases of TB, allergies, asthma, dementia, diabetes, blood disorders, cancer, sickle cell disease, mental illness, chest pain, anemia, bleeding tendency, lymphoid swellings, excessive breaths, high blood pressure, back pain, nausea, vomiting or kidney disease have been reported during her medical check-ups. She does the normal daily activities without any aids. Philistine also goes out to play hockey as one of her routine physical exercise. Part 2: Interview Critique and Summary Introducing the Client Philistine Houston was born on Feb 29th 1964 in Edly. She is a 50 year old single lady of Australian nationality and she stays with her dog in her house, which is next to her father’s. She has no any advanced medical directives. Her parents are still alive and lives next door. She has one sister. Summary of interview data relevant to development of Life Span Erik Erikson developed one of the most known psychosocial theory that we can use to describe the lifespan development of the client. The ego identity shapes the beliefs, values, and ideals that guide and shape a person’s behavior. According to Erik Erikson’s (2014,p.51) stage number 3 of psychosocial crisis; initiative vs. guilt whose basic virtue is purpose, children between the age of 3 and 5 are involved in many playing activities. They explore by making art, using tools etc. Within the client’s health history, she reveals that she broke her arm when she was a tender age and had to be treated in children’s hospital. She may have broken her arm probably trying to complete a self-driven action for her own purpose. Erik Erickson explains that children at this stage may sought to risk-taking and daring behaviors that involve self-limits. Philistine currently lives in a safe environment where robbery or violence is a rare event. She says that one can walk to the beach at any time of the night without fearing for his/her life. In stage six of Erikson’s theory of psychosocial development Philistine choses isolation. There is no intimate relationship developed with other people who are not her family members. She is not committed to any relationship that can lead to marriage. According to Ericson, avoiding intimate relationship can lead to loneliness, isolation and depression. This is Philistine’s situation, there is no virtue of love in her life, even though she admits in the interview that she is not afraid of a partner or an ex-partner. She believes that everyone is entitled on his/her opinion and no one should question or ignore one another’s opinion. Her teaching career is well established and almost coming to an end in the next five years. Ericson’s theory number seven leads to the virtue of care. This is achieved through giving back to the society by raising children, being actively involved in communal activities, and being of high productivity at work (Barkway 2009,p.55). The client is more stressed in her life by her career. The stresses range from many books requiring marking to taking interviews, lesson preparation, and regular staff meetings and pressure to meet deadlines. However, she assures that when she executes her plans as arranged before, there is minimal stress to worry about. Occasional headaches are also experienced as a result of cold. For her, drinking a strong cup of coffee and relaxing somehow reduces the headaches. She is not actively involved in alcohol drinking and smoking. She hadn’t been smoking for almost a year ago. She doesn’t use hard drugs like Marijuana, cocaine etc. She enjoys reading and watching movies at her leisure time as a way of relaxing. Her personal strength in mediating people, conflict resolution and peace making. She approaches this with the attitude that everyone is entitled to his/her opinion, and she has to respect whatever the opinion one has. She likes to see people get along well with one another. These, she does by solving differences between peers as a mediator and a peace maker. According to the Theory of Reasoned Action (McLeod 2008, p.3) that relates attitudes attitude-behavior, social relevance behaviors and health behaviors are normally under volitional control. The intention of the person performing the behavior is the immediate determinant as well as the best predictor of the course of that behavior. The client believes that by taking a cup of strong coffee when she encounters occasional headaches slows the action and she becomes well. Another closely related theory on attitudes and the behavior of attitude is the Theory of Planned Behavior. The intention of taking coffee when she is experiencing headaches is a function of two main determinants; her evaluation to perform the behavior and the subjective norm. Generally, different people have different intentions of performing a given action, given that they evaluate it positively. Another psychosocial theory, the Self-efficacy Theory, can also be related to the client’s behavior of taking a cup of coffee to do away with headaches. Under this approach, one’s behavior is perceived using two main determinants; self-efficacy and expected outcomes, whether positive or negative (Burger 2009, p.23). Identification of relevant anatomy and the physiological process that underpins the selected Philistine is actively involved in regular activity and exercise despite having a busy day at school. She goes out to play hockey 3 times a week. She is very careful on her weight since she turned 40 after managing her obesity. As a measure of weight control, she takes food with little sugars, and uses soya milk for plant proteins. She doesn’t need any assistance with normal daily activities such as dressing, mobility, going to the toilet etc. since she is very active and has no physical disability. She takes three meals a day and enough water, with a lot of caution on the amount of sugar and salt in the foods. Reflection on my Learning In the interview between the health history interview is always carried out with a specific purpose. For me as a student, the health history interview is to complete a write-up for my teacher. At professional practice, the interview is important for completion of forms provided by healthcare institutions to make a follow-up concerning a client’s healthcare and testing of hypothesis generated when a review of the chart is done. As a clinician, there should be a balance between your provider-centered goals for the interview with the client-centered goals. In eliciting a patient’s history through interview, one uses the most of the every day’s interpersonal skills, but with unique differences. Most importantly is the primary goal of the interview between a clinician and a patient is to improve the patient’s wellbeing, unlike in social conversations where one can freely express their needs and interests and are only responsible for themselves. At the basic level, a conversation between a healthcare professional with a patient has three main purposes; to build trust and a supportive relationship, to obtain helpful information and to offer helpful information. Effectively relating with patients is one of the skills that is valued in the field of clinical care. Gathering of information from patients requires use of techniques that can promote trust in the most respectful way. You have to allow the patient to unfold his/her story in full and detailed. Having a supportive interaction will make the patient to ease up and share the information much needed for therapeutic relationship between the patient and the clinician. Illnesses can make people feel discouraged and/or isolated. This calls for clinicians interacting with patients to develop an atmosphere with a feeling of connectedness between them and the patient through careful listening and understanding. Suggested Changes for this Interview Technique in the Future The interview for more sensitive topics such as sexual history, alcohol and drug abuse, mental health history, and family violence should be done with specific approaches (Forbes & Watt 2012, 25-27). Discussions on sensitive or emotionally charged matters are challenging, even seasoned clinicians can feel discomfort with such topics. According to this interview, the clinician opted to ask the questions directly to her client without explaining to the patient why she needs certain information regarding these topics. The clinician should at least explain to the patient why she is asking questions related to these topics. This will make feel comfortable and less apprehensive (Bate 2011, p.25). For instance, in the case of seeking information on the use of hard drugs, the clinician can frame a question like, “ The use of drugs such as marijuana and cocaine have been implicated to have adverse effects on human health and behavior and expose them to risk for some diseases, I normally ask the following question for all my patients.” Information on sensitive topics should also be asked using opening questions depending on the kind of data needed for a particular assessment. Questions on sexual behavior can be introduced at several points during the interview as part of elaboration and clarification of the patient’s story. The clinician may use questions such as, “To do an assessment of risk for some diseases, I need to obtain some leading information about your sexual health practices”. This part of interview that deals with sensitive issues provides a valued history that is very important to any patient because it makes life worth to live, and should be approached more skillfully. References Read More