response to serna

Discussion #1- Case #3

What are the barriers to interpersonal communication?

Communication is typically difficult for pregnant teenagers since the majority are frequently anxious, fearful, and concerned about how the other person would see them. This can ultimately result in feelings of guilt. Since of emotions of humiliation, transgender people may also avoid open contact with their medical staff because they are reluctant to admit their true identities (Hornberger, 2017). Focusing on building relationships with patients will help healthcare providers gather the data needed for patient care. Despite possessing crucial clinical abilities to aid in building therapeutic relationships with their different client cohorts and for appreciating a patient's particular viewpoint, there are persistent barriers to proper interpersonal communication among healthcare practitioners. Language and cultural barriers as well as a lack of established transparency and trust by the healthcare professional may prevent the pregnant teen from speaking openly. Effective communication with the transgender guy may be hampered by the healthcare professional's unequal engagement style or by personality conflicts that may be partially attributable to the patient's background, such as being homeless. Barriers based on gender could also be a major contributing element. Regardless of age, gender, or condition, effective communication tactics should guarantee patients' comfort and concentrate on building a relationship (Shulman et al., 2017).

Procedures and Examination Techniques for Use during the Patient’s Physical Examination

Taking the patient's history, including any social or cultural issues that might be related to the care, and determining a diagnosis, for example, based on test results, are both steps in the process of performing a physical examination on the pregnant adolescent. It also includes discussing the findings with the adolescent in a confidential and welcoming setting to assist in determining the next step. A urine testing kit could be used to confirm any early indicators of pregnancy, such as morning sickness and missed or light periods, which are among the particular screening processes. Additional crucial examinations for the adolescent include routine blood pressure checks, an abdominal exam from 24 weeks of pregnancy, and the taking of weight for the purpose of calculating body mass index (BMI). Another option is an ultrasound examination, which aids in estimating gestational age and spotting multiple pregnancies (Hornberger, 2017). After taking the patient's vitals and the relevant history, the treatments and examination techniques employed for the male transgender patient include evaluating the breast tissue health for any anomalies and doing a pelvic health appraisal (Shulman et al., 2017). The evaluation specifically includes a pelvic exam that aids in determining issues with the uterus, ovaries, and cervix, performing a pap test, and a test for sexually transmitted infections.

Subjective, Objective, Assessment, Planning (S.O.A.P.) Approach for Documenting Patient Data

           The identified procedure aids healthcare personnel in managing patients in a planned and organized way and is a widely used documentation methodology in modern healthcare settings. The subjective category focuses on the individual opinions and sentiments of the patient on the current disease symptoms (Podder et al., 2020). The presenting complaint, its start, location, length, nature, relieving influences, and the temporal patterns of the disease are a few examples of the data that may be used. A list of the doses and frequency of the medications used is also included, as well as the pertinent medical history of the patient. The characteristics that can be seen, measured, felt, or heard make up the patient's collected vital signs and are included in the objective category, which describes the outcomes of the healthcare professionals' evaluations. The results of the physical examination, laboratory information, and imaging tests are also included (Podder et al., 2020). The synthesis of the subjective and objective facts that aid in making a diagnosis is documented in the assessment section. Notably, the section may use a differential diagnosis to consider one or more diagnoses for the condition of the presenting patient. The plan, which details the precise actions to take in resolving the patient's presenting problem, is included in the final part. It may specifically mention the need for extra tests and advice, which is significant. The necessary therapy, patient education and counseling, and specialist referrals are a few examples of plan metrics.

References

Hornberger, L. (2017). Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient.  Pediatrics,  140(3), e20172273.  https://doi.org/10.1542/peds.2017-2273 Links to an external site.

Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes.  StatPearls.

Shulman, G., Holt, N., Hope, D., Mocarski, R., Eyer, J., & Woodruff, N. (2017). A review of contemporary assessment tools for use with transgender and gender nonconforming adults.  Psychology Of Sexual Orientation And Gender Diversity,  4(3), 304-313.  https://doi.org/10.1037/sgd0000233