Week 1 Advanced Health Assessment
My patient: 38-year-old Native American pregnant female living on a reservation
Each patient you meet you will have different techniques and ways of going about communication with them depending on their culture and beliefs. It is important to understand what is important to them. Ask yourself what do they value most? You want to be able to connect with them to get an accurate history to provide care. The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. (Jamieson H,2019)In my situation with my patient being of the Native American decent livening on a reservation whom is pregnant I can already assume she does not have much interaction with the outside world such as those outside the reservation. She mainly probably stays with those who live around her and live off the land with little unhealthy habits since nature is very important in this culture.
My interview techniques to obtain a health history would need to be based on her lifestyle. I need to make sure I am wording them correctly so that she can understand what I am needing from her. Certain health information that is important to us may not be pertinent to the patient. I need to target my questions towards her lifestyle. The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient. (Gray LC,2018) I also need to base a lot of my question on the fact she is pregnant. I need to ensure she Is healthy not only for herself but for the baby. I may have to redirect and reword my question multiple times to obtain accurate information. With this patient living on a reservation I need to ask about her diet and environmental factors since my way of life Is different than hers I need to first understand how she lives. The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. (Dunham M,2018)I then need to focus on potential health risk based on first this patient age. This patient is 38 years old and is pregnant. This is automatically a high-risk pregnancy due to her age. 35 is considered geriatric pregnancy. This increase the risk for many health concerns for her and the baby. Also, her living situation can at time be difficult for her and baby depending on what type of reservation she lives on. I need to ensure she has quick access to medical care and is receiving the proper supplements. Many native American cultures believe in herbal and home remedies which can sometimes be harmful or interact with other medications. Some questions that need to be asked I order to obtain an accurate health history are the following: Do you have any allergies to medication?Is this your first child? If not, how many children do you have, and did you have a C-section?
What medication including herbal supplements are you taking?Have you ever had any major surgeries?Have you ever been hospitalized for any reason including mental health reasons? What is your family history?Have you been having any complications that you have noticed or concerns?