Case Study Analysis

To prepare:
Reflect on your experience as an advanced practice nurse and on the information provided in the Week 1 Learning Resources on building a health history and the Week 2 Learning Resources on diversity issues in health assessments.
By Day 1 of this week, your Instructor will assign a case study for this Assignment. Note: Please see the Course Announcements section of the classroom for your Case Study Assignment.
Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of your assigned patient.
Consider how you would build a health history for the patient. What questions would you ask? How might you target your questions based on the patient’s social determinants of health? How would you frame the questions to be sensitive to the patient’s background, lifestyle, and culture?
Identify any potential health-related risks, based on the patient’s age, gender, ethnicity, or environmental setting, which should be taken into consideration.
What risk assessment instruments would be appropriate to use with this patient?
What questions would you ask to assess the patient’s health risks?
Select one (1) risk assessment instrument discussed in the Learning Resources, or another tool with which you are familiar, related to your selected patient.
Develop five (5) targeted questions you would ask the patient to build their health history and to assess their health risks.
Think about the challenges associated with communicating with patients from a variety of specific populations. What communication techniques would be most appropriate to use with this patient? What strategies can you as an APRN employ to be sensitive to different cultural factors while gathering the pertinent information?

Assignment: Building a Health History With Cultural and Diversity Awareness
Include the following:
Explain the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Be specific.
Explain the issues that you would need to be sensitive to when interacting with the patient, and why.
Describe the communication techniques you would use with this patient. Include strategies to demonstrate sensitivity with this patient. Be specific and explain why you would use these techniques.
Summarize the health history interview you would conduct with this patient. Provide at least five (5) targeted questions you would ask the patient to build their health history and to assess their health risks. Explain your reasoning for each question and how you frame each for this specific patient.
Identify the risk assessment instrument you selected, and then justify why it would be applicable to your assigned patient. Be specific.
Case Study #1
JB, a 39-year-old Caucasian female, is seen by her care provider for a complaint of productive cough, weakness, and “I just haven’t felt good for the past 2 weeks.” The care provider completes an assessment of listening to her lungs by having her take 2 deep breaths, informs her that her lungs are clear, and instructs her to take OTC cough medication and hydrate well. The next day, JB feels worse and visits a different care provider who, at this time, assesses her head, eyes, ears, nose, throat; auscultates her heart sounds and hears a murmur (which she did not know she had); auscultates her lungs by having her to take 4 deep breaths, performs percussion techniques, and tells her there is fluid on her lungs; examines her lower extremities and notices that there is bilateral 2+ pitting edema; and lastly, reviews her vital signs and tells her that her heart rate is 120, respirations are 22, and she has a temp of 101.

Questions:

1.) Is the health history about the patient’s complaint thorough?

2.) Which provider’s examination would provide the patient with an accurate diagnosis and treatment plan?

3.) What diagnoses (we call them differential diagnoses) would be considered, and how would you rule them out to come up with an actual diagnosis?

 

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