Case #2: “Asian female, 55, living in a high-density poverty housing complex.” “A pre-school-aged white female from a rural community.”
Interpersonal Communication Obstacles
Numerous factors, such as the medical client’s age, norms, family status, social status, or cultural beliefs, influence communication flow and the ability to establish interpersonal links in any interview. A lack of transparency and trust issues may be a critical barrier to effective interpersonal communication in the selected patient scenarios. When the medical practitioner and their patient have trust issues, communication becomes difficult. This challenge may cause the patient in the selected case to refuse to open up and share the necessary clinical care details, which are also required to properly comprehend the patient’s scenario and plan for their intervention. Some patients may feel anxious because of problems with trust and openness, and they may not share important information that is needed for their treatment, setting of goals, and care plan (Alshammari et al., 2019).
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The lack of emotional safety and security, particularly on the patient’s side, is the next impediment to effective interpersonal communication. The medical client is uncomfortable sharing their ideas and feelings, expressing their health problems, and becoming authentic because they are afraid of being judged, ridiculed, or turned off.(Blair & Smith, 2012) When a client is emotionally insecure, they feel a lot of fear, which makes it hard for them to communicate well with other people and make good connections with them.
During the clinical interview phase, communication style can be a significant barrier to establishing effective interpersonal communication. At times, the client and the clinical profession may use different communication methods (Alshammari et al., 2019). For example, when one party, the patient or the clinician, prefers indirect communication while the other prefers direct communication, Furthermore, some medical clients may prefer detailed information, which can create a barrier to interpersonal communication when the clinician is unable to provide it. Because of how they talk to each other, doctors and nurses may not understand their patients.
Finally, the poor clinical setting for the assessment, as well as noise, may be a barrier to interpersonal communication. Every clinical evaluation chooses a significant location and works toward techniques and mechanisms for practical and effective communication approaches (Kim & White, 2018). Inadequate management techniques and ignorance of impending issues or problems may reduce the confidence levels of the selected patient’s scenarios and the expected effectiveness in communication (Blair & Smith, 2012). For example, the elderly patient’s high-density poverty housing complex is full of distractions, and the client may be unable to disclose every required clinical detail regarding her health condition, as well as other challenges related to her illness.
Examining Approaches and Procedures to be Used in Scenario #2
During the patient’s physical examination, I will use clinical examination approaches such as inspection, palpation, percussion, and auscultation. In order to determine what is normal and what is abnormal, inspect each body system using the senses of sight, smell, and hearing during the inspection. From head to toe, you must examine the body system to determine how it is colored, sized, located, moving, cool and hot, smelling, symmetrical, and hearing. I will carefully deliberate and visually observe the client’s behavior, focusing on the most important issues, such as changes in their body. Palpation requires you to touch the patient with varying degrees of pressure on different parts of your hand. Because your hands are your tools, it is critical to keep your fingernails short and warm. Wear gloves when performing palpations on mucous membranes or areas in contact with bodily fluids. Tender spots should be checked last. Light palpation can be used to detect surface irregularities by feeling for them. When pressing the skin with your finger pads, use light pressure between 1/2 and 3/4 inch (about 1 and 2 cm). Texture, tenderness, temperature, moisture, elasticity, pulsations, and masses should all be evaluated. Palpation is the most accurate way to determine the size, shape, tenderness, symmetry, and mobility of internal organs and masses. Depress the skin between 1 1/2 and 2 inches with firm, deep pressure (about 4 to 5 cm). Apply firmer pressure if necessary by placing one hand over the other. Percussion entails using the 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. Percussion identifies organ borders, shapes and positions, and 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). (Kohtz et al., 2017).
Patient Data Documentation (S.O.A.P. Approach) (S.O.A.P. Approach)
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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). (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 other words, objective data refers to details that can be 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’s diagnosis. Thus, this part states the client’s primary and probable differential diagnosis. The last part of the SOAP is the plan. This is what the health care provider will do to treat the patient’s concerns, such as ordering medications and providing education. 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). (Briscoe & Harding, 2020).
References
Alshammari, M., Duff, J., & Guilhermino, M. (2019). (2019). Barriers to nurse-patient communication in Saudi Arabia: an integrative review. Nursing, B.M.C., 18(1), pp. 1-10.
Briscoe, J., & Harding, T. (2020). (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). (2012). Nursing documentation: frameworks and barriers Modern Nursing, 41(2), pp. 160-168.
Kim, B., & White, K. (2018). (2018). How can health professionals enhance interpersonal communication with adolescents and young adults to improve health care outcomes? A systematic literature review 198-218 in International Journal of Adolescence and Youth.
Kohtz, C., Brown, S. C., Williams, R., & O’Connor, P. A. (2017). (2017). Physical assessment techniques in nursing education: a replicated study. 287-291 in Journal of Nursing Education, 56(5).