Health History: Subjective Data
P, a 56-year-old man, presented with symptoms of general body malaise, poor appetite, swollen legs and ankles, urinating most of the time, especially at night, nausea, and difficulty concentrating, upon which he was diagnosed with chronic kidney failure. These symptoms, evaluated by means of the PQRST method, are evidence of the chronicity of Mr. P’s disease and its role in his functioning. He reckons these symptoms impair his health since he also expresses anxiety that they may be cancer. In terms of past medical history, Mr. P was diagnosed with hypertension five years ago and now takes Lisinopril daily in the morning. He was diagnosed with type 2 diabetes mellitus eight years ago, which he controls with Metformin medication, taken twice daily. He denies any allergies. His vaccination record is up-to-date, including tetanus, diphtheria, influenza, pneumococcal, and hepatitis B vaccinations received annually or as his healthcare provider recommends. The Family Medical History indicates that the father had high blood pressure, and the mother had type 2 diagnosed in their 50s and died in their 70s due to the associated complexities of these two diseases.
In reviewing Mr. P’s systems, he denies any chest pain or palpitations, which means he has no cardiovascular issues. Respiratory-wise, he informs that there is no cough or breathlessness, indicating no respiratory distress. However, he admits to feeling frequent heartburn, indicating a possible gastrointestinal problem. Neurologically, Mr. P. does not state having any headaches or other sensation changes, implying that his neurological functions must usually work. Furthermore, he notes that he suffers from joint pains at times, which may be suggestive of a potential musculoskeletal problem. To sum up, although his review of systems shows minor discomfort in gastrointestinal and musculoskeletal areas, no findings are alarming other body system issues.
Considerations
Developmentally, Mr. P illustrates the traits related to generativity vs stagnation as per Erikson’s psychological theory. He has completed his supreme stage achievements, as indicated by his active participation in his career, family life, and community. For example, he has managed his home responsibly by raising children and being actively involved with the community, demonstrating that he is satisfied and contributing to society. Culturally, Mr. P’s perception and actions are molded by his cultural setting. He upholds cultural conventions in which the culture is based upon the holistic concept of healthcare that embraces the integration of conventional medicine with traditional healing. For example, he combines alternative therapies with other medications to solve his health problems. From both psychological and social perspectives, Mr.P enjoys the benefits of evident support networks. His family gives emotional support, the religious community provides spiritual enlightenment, and social activities build relationships. His support system comprises his family, close friends, and medical personnel, who maintain his good health and capacity to overcome health adversities. As for collaborative resources, Mr. P has benefited from different institutional services such as community resources, family assistance, social support, and health services. All these collaborative resources are valuable to Mr. P in handling his health and ensuring patient-centered and customized care (Luyckx et al., 2020).
Physical Examination: Objective Data
In the physical examination, Mr. P’s health condition across the body systems was thoroughly evaluated. In the HEENT exam, Mr. P appeared normocephalic and atraumatic without pathology, normal visual acuity, intact extraocular movements, and clear conjunctiva. There was no discharge or inflammation on his ears, which seemed remarkable, and his nose was evident, with both nostrils patent. The throat examination showed no erythema or exudate, and the uvula was midline. A neck examination was subsequent, and no mass or tenderness was palpated. His neck was pliable. The thyroid gland was normal in size and consistency, with no apparent lymph nodes in the neck region.
Mr. P’s respiratory system presented normal bilaterally sounds; no abnormalities such as wheezes, crackles, and rhonchi were observed. His respiratory rate was within the norm of normality. The regular rhythm was noted audibly on a detailed cardiovascular system examination with no murmurs, gallops, or rubs. Peripheral pulse was felt and was equal on both sides. Next, in the neurology domain, Mr. P displayed perfect functioning of all the cranial nerves, ample sensation, and full power of all extremities. There were no focal neurological deficits detected. After evaluation of the gastrointestinal system, a soft, non-tender abdomen with audible bowel sounds in all quadrants was observed. No organomegaly or masses were noted. The musculoskeletal examination shows Mr. P has normal functions in all his extremities without any deformity or swelling; his strength is standard in both hands. Lastly, examining the peripheral vascular system, peripheral pulses were palpable and equal bilaterally, with no signs of edema noted in the upper limbs. Nevertheless, +2 pitting edema was present widely in both legs. Overall, Mr. P’s physical examination findings are within the normal range for those body systems examined, and no acute abnormalities are detected except edema on the lower extremities.
Needs Assessment
Based on Mr. P’s health history and physical examination findings, two health education needs are identified: management of chronic kidney disease (CKD) and prevention of the complications that are related to diabetes mellitus and hypertension. In terms of the first education need, which is concentrating on managing CKD, research conducted by Wheeler et al. (2021) demonstrated the potential of patient education in CKD management to delay the progress of the disease and reduce the chances of adverse reactions. The research identified that individuals who applied structured teaching methods improved their understanding of CKD, adherence to treatment plans, and ability to utilize self-management skills. Given Mr. P’s physiological, developmental, cultural, and psychological issues, his ability to understand the management of chronic kidney disease is likely to be negatively impacted by the level of his health literacy, his cultural beliefs regarding illness and treatment, and the psychosocial support groups. Harnessing Mr. P’s advantages, which could include his family members’ involvement in managing his health and healthcare services’ accessibility, will be necessary to create awareness of diabetes management. Combining home healthcare experts and local community projects services like counseling and walk-in clinics can further expand Mr. P’s medication compliance and life adjusting (Kelly et al., 2021).
Education on the second need, which deals with the prevention of complications associated with diabetes Mellitus and hypertension, according to a study by Swatling et al. (2021), highlights the importance of patient in improving self-care behaviors and the risk of complications in patients suffering from both diabetes and hypertension. It underlines the fact that training should be in the local language and take into consideration culture. Interventions will, therefore, aid in promoting dietary modifications, medication adherence, and regular monitoring of blood glucose and blood pressure levels (Sun et al., 2021). For Mr. P, these include physiological, developmental, cultural, and psychosocial considerations. Such are the primary factors to be considered while facilitating the provision of culturally sensitive educational materials that are language-appropriate and favor the patient’s comprehension and adherence to the prescribed preventive measures. Mr. P’s commitment to steward his health and the efforts of his family and healthcare professionals will positively affect education regarding diabetes and hypertension management. The collaborative healthcare resources contributed by community health programs and wellness initiatives, for example, can play an extra role in the education and implementation of preventive behaviors among the community in the long run.
Reflection
Completing the comprehensive health profile and physical assessment for Mr. P was a precious learning experience for me and offered insights into the complexities of patient care visits. The encounter with the interviewee happened in the clinical setup, whereby doubts and feelings of anxiety were well managed. My approach was empathetic and patient-centered; the main focus was listening and rapport building. The interview was done in the morning when all parties were well-rested and fully alert. During the process, therapeutic communication tools like active listening and open-ended questions were used to provide a safe and inviting environment and keep Mr. P engaged and involved.
In assessing the communication approaches and diagnostic practices that I underwent with Mr. P, I realized that many of these proved to be valuable approaches in soliciting critical information and developing trust with Mr. P. Nevertheless, communication challenges also emerged from time to time, which significantly intensified by Mr. P status as an anxious person, who sometimes struggled to express himself clearly. However, I used affirmative statements and reassurance to ensure he felt acknowledged and reassured. The same applies in the future; I will continue to prioritize empathy and patience, which may require disparate communication approaches to better meet patients’ needs. Generally, the evaluation session turned out as planned, evaluating Mr. P’s health status comprehensively and discovering the main domains of health education. Nonetheless, some issues surfaced unexpectedly, such as time management and emotional problems during the interview. Also, I lacked more information on Mr. P’s past, more details about his psychological background, and some information about his social networks for the assessment, education, and treatment planning. I plan to start with more data collection and identify areas that need more attention to ensure that I organize my work well.
References
Luyckx, V. A., Cherney, D. Z., & Bello, A. K. (2020). Preventing CKD in developed countries. Kidney International Reports, 5(3), 263-277.https://doi.org/10.1016/j.ekir.2019.12.003
Sun, D. Q., Jin, Y., Wang, T. Y., Zheng, K. I., Rios, R. S., Zhang, H. Y., … & Zheng, M. H. (2021). MAFLD and risk of CKD. Metabolism, 115, 154433.https://doi.org/10.1016/j.metabol.2020.154433
Kelly, J. T., Su, G., Zhang, L., Qin, X., Marshall, S., González-Ortiz, A., … & Carrero, J. J. (2021). Modifiable lifestyle factors for primary prevention of CKD: a systematic review and meta-analysis. Journal of the American Society of Nephrology, 32(1), 239-253.https://doi.org/10.1681/ASN.2020030384
Swartling, O., Rydell, H., Stendahl, M., Segelmark, M., Lagerros, Y. T., & Evans, M. (2021). CKD progression and mortality among men and women: a nationwide study in Sweden. American Journal of Kidney Diseases, 78(2), 190-199.https://doi.org/10.1053/j.ajkd.2020.11.026
Wheeler, D. C., Stefánsson, B. V., Jongs, N., Chertow, G. M., Greene, T., Hou, F. F., … & Heerspink, H. J. (2021). Effects of dapagliflozin on major adverse kidney and cardiovascular events in patients with diabetic and non-diabetic chronic kidney disease: a prespecified analysis from the DAPA-CKD trial. The Lancet Diabetes & endocrinology, 9(1), 22–31.https://doi.org/10.1016/S2213-8587(20)30369-7
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