23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him
23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him
Cultural, Spiritual, Nutritional, & Mental Health Disorders
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
| Case 1 | Case 2 | Case 3 | |
| Subjective Data | |||
| Chief Complaint (CC) | “I came for my annual physical exam, but do not want to be a burden to my daughter.” | “I am here for my annual physical exam and have been having vaginal discharge.” | “Annual physical exam” |
| History of Present Illness (HPI) | At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs. | 32-year-old Hispanic/Latina pregnant lesbian – her pregnancy has been without complication thus far. She has been receiving prenatal care from an obstetrician. She received sperm from a local sperm bank. | 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle. |
| PMH | Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis | ||
| PSH | S/P cholecystectomy | ||
| Drug Hx | Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily. | Current Meds: prenatal vitamins and takes Tylenol over the counter for aches and pains on occasion | Current Meds: denied |
| Allergies | No allergies to food or medications. | ||
| Family Hx | She has a strong family history of diabetes. Gravida 1; Para 0; Abortions 0. | He has a family history of diabetes, hypertension, and alcoholism. | |
| Review of Systems (ROS) | |||
| General | + weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills. | No fatigue, fever, or chills. | No recent weight gains of losses, fatigue, fever, or chills. |
| Head, Eyes, Ears, Nose & Throat (HEENT) | No changes in vision or hearing, no difficulty chewing or swallowing. | ||
| Neck | No pain or injury | No pain or injury | |
| Respiratory | |||
| CV | no chest discomfort or palpitations | ||
| GI | |||
| GU | no urinary hesitancy or change in urine stream | ||
| Integument | multiple bruises on his upper arms and back. | multiple piercings, and tattoos. Old scars related to “cutting” | history of eczema – not active |
| MS/Neuro | + falls x 2 within the last 6 months; no syncopal episodes or dizziness | no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements. | no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements |
| Objective Data | |||
| PE | B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 | B/P 128/76; Pulse 83; RR 16; Temp 99.0; Ht 5,6; wt 128; BMI 20.98 | B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6 |
| General | 23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress. | ||
| HEENT | Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. | Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. | Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. |
| Lungs | CTA AP&L | CTA AP&L | CTA AP&L |
| Card | S1S2 without rub or gallop | S1S2 without rub or gallop | S1S2, +II/VI holosystolic murmur; without rub or gallop |
| Abd | benign, normoactive bowel sounds x 4 | benign, normoactive bowel sounds x 4 | benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. |
| GU | external genitalia intact, no lesions or masses. White copious discharge with an amine odor; no cervical motion tenderness; adnexa intact. | ||
| Ext | no cyanosis, clubbing or edema | no cyanosis, clubbing or edema | no cyanosis, clubbing or edema |
| Integument | multiple bruises in different stages of healing – on his upper arms and back. | intact without lesions masses or rashes. | intact without lesions masses or rashes. |
| MS | |||
| Neuro | No obvious deformities, CN grossly intact II-XII | No obvious deficits and CN grossly intact II-XII | No obvious deficits and CN grossly intact II-XII |
Once you received your case number, answer the following questions:
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
- Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?
Submission Instructions:
- Your instructor will assign you your case number and you will post the case number you have been assigned
- Your initial post should be at least 600 words, formatted and cited in current APA style with support from at least 2 academic sources.
Requirements: 600 words
I have case study # 3.
here is the rubric, please follow.
Grading Rubric
Your assignment will be graded according to the grading rubric.
| Discussion Rubric | |||||
| Criteria | Ratings | Points | |||
| Identification of Main Issues, Problems, and Concepts | Distinguished – 5 points Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts. | Excellent – 4 points Identifies and demonstrate an accomplished understanding of most of issues, problems, and concepts. | Fair – 2 points Identifies and demonstrate an acceptable understanding of most of issues, problems, and concepts. | Poor – 1 point Identifies and demonstrate an unacceptable understanding of most of issues, problems, and concepts. | 5 points |
| Use of Citations, Writing Mechanics and APA Formatting Guidelines | Distinguished – 3 points Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors. | Excellent – 2 points Effectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors. | Fair – 1 point Ineffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail. | Poor – 0 points Ineffectively uses the literature and other resources to inform their work. An unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention. | 3 points |
| Response to Posts of Peers | Distinguished – 2 points Student constructively responded to two other posts and either extended, expanded or provided a rebuttal to each. | Fair – 1 point Student constructively responded to one other post and either extended, expanded or provided a rebuttal. | Poor – 0 points Student provided no response to a peer’s post. | 2 points | |
| Total Points | 10 | ||||
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