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Running Head: COMPLETE PATIENT ASSESSMENT Complete Patient Analysis & Teaching Tool Proposal Andrea InostrozaSouthern New Hampshire University NUR-3251
COMPLETE PATIENT ASSESSMENT Complete Patient Analysis & Teaching Tool ProposalIntroduction Tina Jones, African American female, she is 28 years old; comes in needing a pre-employment exam as a requirement for her health insurance at her new job. Tina speaks primarily English. Tina does not complain of any acute symptoms. Tina has a medical diagnosis of Type II diabetes and asthma. Tina’s diabetes is well controlled with diet, Metformin, and daily blood glucose monitoring. Tina looks forward this new career. Patient AnalysisInterviewing There are many things to consider in order to accomplish a good and efficient interview. First of all there should always be a therapeutic relationship; a caring relationship that would help accomplish good communication, building good interpersonal relationships, where the patients feels that we really care for their concerns and helping them explore their feelings and their options in different situations or what their outcome may be and lastly their treatment plan (Jensen, 2015).Empathy should always be implemented into any interview or assessment. “Caring encompasses your empathy for and connection with the patient” (Jensen, 2015, p 21). We also must be aware of the nonverbal communication which is as important, this consist of how we appear physically our posture, our facial expressions, gestures, tone of our voice, using plain understandable language and touch are also very important. If we roll our eyes, appear stressed which we often are or appear disgusted can create a mistrust with our patients (Jensen, 2015).The way the question are asked can lead to answers that are the answers we want to hear not answers that are truthful, many of our patients may feel judge or guilty of their choices if the 2
COMPLETE PATIENT ASSESSMENT way we interview makes them feel pressured (Jensen, 2015). Because of this I made sure when I interviewed Tina this was done in a personable way, the questions that were asked were appropriate to the context and nonjudgmental, so I could develop trust and she didn’t have to feeloffended or uncomfortable in any way. I made sure there was an explanation to everything that was done and showed that I was empathetic to her situation. And lastly but very important part ofany interview should be education, educating each patient in every opportunity we get ensure positive outcomes in our patients.Data Collection The way I collected the data was using multiple techniques, first the assessment was always started with the least invasive way which in inspection, this was done for each part of the body in the different systems; by inspecting I was able to observe not only the physical appearance but also the patients behaviors. The I auscultated Tina’s organs, to hear for abnormalities. Next was percussion, this technique is used to produce a sound or elicit tenderness(Jensen, 2015). And lastly is palpation since the most invasive is the technique that is saved for