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.

Chief Complaint (CC)

“I came for my annual physical exam, but do not want to be a burden to my daughter.”

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.

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.

Review of Systems (ROS)

General

+ weight loss of 25 lbs over the past year; no recent 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

GU

no urinary hesitancy or change in urine stream

Integument

multiple bruises on his upper arms and back.

MS/Neuro

+ falls x 2 within the last 6 months; no syncopal episodes or dizziness

Objective Data

PE

B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

HEENT

Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

Lungs

CTA AP&L

Card

S1S2 without rub or gallop

Abd

benign, normoactive bowel sounds x 4

Ext

no cyanosis, clubbing or edema

Integument

multiple bruises in different stages of healing – on his upper arms and back.

Neuro

No obvious deformities, CN grossly intact II-XII

Once you received your case number, answer the following questions:

1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.

2. Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.

3. 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?

Your initial post should be at least 550 words, formatted and cited in current APA style with support from at least 3 academic sources.