ANSWER
Communication is often difficult for pregnant teenagers because they are frequently anxious, fearful, and concerned about how others perceive them. This can eventually lead to feelings of guilt. Transgender people may avoid open contact with their medical staff due to feelings of embarrassment, as they are hesitant to admit their true identities (Hornberger, 2017). Building relationships with patients will assist healthcare providers in gathering the data required for patient care. Despite having critical clinical abilities to aid in the development of therapeutic relationships with their various client cohorts and appreciating a patient’s unique point of view, there are persistent barriers to proper interpersonal communication among healthcare practitioners. Language and cultural barriers, as well as the healthcare professional’s lack of established transparency and trust, may prevent the pregnant teen from speaking openly. Effective communication with the transgender man may be hampered by the healthcare professional’s unequal engagement style or by personality conflicts caused in part by the patient’s background, such as being homeless. Gender-based barriers could also play a significant role. Regardless of age, gender, or condition, effective communication strategies should ensure patients’ comfort while focusing on relationship building (Shulman et al., 2017).
Procedures and Examination Techniques for Use During the Physical Examination of the Patient
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Taking the patient’s history, including any social or cultural issues that may be related to the care, and determining a diagnosis, for example, based on test results, are both steps in performing a physical examination on the pregnant adolescent. It also includes discussing the findings with the adolescent in a private and welcoming environment to help determine the next step. A urine testing kit could be used to confirm any early pregnancy indicators, such as morning sickness and missed or light periods, which are among the specific screening processes. Routine blood pressure checks, an abdominal exam beginning at 24 weeks of pregnancy, and weight taking for the purpose of calculating body mass index are all important examinations for adolescents (BMI). An ultrasound examination is another option for determining gestational age and detecting multiple pregnancies (Hornberger, 2017). After taking the patient’s vitals and relevant history, the male transgender patient’s treatments and examination techniques include evaluating the breast tissue health for any anomalies and performing a pelvic health appraisal (Shulman et al., 2017). The evaluation includes a pelvic exam to help determine problems with the uterus, ovaries, and cervix, a pap test, and a test for sexually transmitted infections.
Approach to Documenting Patient Data Based on Subjective, Objective, Assessment, and Planning (S.O.A.P.)
The identified procedure assists healthcare personnel in the planned and organized management of patients and is a widely used documentation methodology in modern healthcare settings. The subjective category focuses on the patient’s individual thoughts and feelings about the current disease symptoms (Podder et al., 2020). The presenting complaint, its onset, location, duration, nature, relieving influences, and the disease’s temporal patterns are a few examples of data that may be used. A list of the medications used, their doses and frequency, as well as the patient’s pertinent medical history, is also included. The characteristics that can be seen, measured, felt, or heard comprise the patient’s collected vital signs and are included in the objective category, which describes the results of healthcare professionals’ evaluations. The physical examination results, laboratory data, and imaging tests are also included (Podder et al., 2020). The assessment section documents the synthesis of subjective and objective facts that aid in making a diagnosis. Notably, the section may employ a differential diagnosis to consider one or more diagnoses for the presenting patient’s condition. The final section includes the plan, which details the precise actions to take in resolving the patient’s presenting problem. It may expressly state the need for additional tests and advice, which is significant. Plan metrics include the required therapy, patient education and counseling, and specialist referrals, to name a few.
References
L. Hornberger (2017). Pregnancy Diagnosis and Pregnancy Options Counseling for Adolescent Patients Pediatrics, 140(3), e20172273, doi:10.1542/peds.2017-2273 External website links
V. Podder, V. Lew, and S. Ghassemzadeh (2020). StatPearls. SOAP Notes.
G. Shulman, N. Holt, D. Hope, R. Mocarski, J. Eyer, and N. Woodruff (2017). A look at some of the most recent assessment tools for transgender and gender nonconforming adults. 304-313 in Psychology of Sexual Orientation and Gender Diversity, 4(3). https://doi.org/10.1037/sgd0000233
QUESTION
Case #3- Discussion #1
What are the stumbling blocks to interpersonal communication?