Functional Assessment Case Study

Functional Assessment Case Study

Considerations When Building a Health History

A culturally competent care starts with awareness of the patient’s social values, biases, and behavior. However, the clinician also has to be aware of their personal cultural beliefs and values first. This week’s discussions case study is about EB, a sixty eight-year-old black female who is a known hypertensive patient. She has come for hypertension follow-up but has a history of glaucoma and loss of vision in the past few years. EB, who lives alone, has four anti-hypertension prescription medications but has forgotten the fourth medications at home. On the same visit, her blood pressure is elevated while the heart rate is normal. There are various socioeconomic factors that should be considered while building her health history.

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Socioeconomic, Spiritual and Lifestyle Considerations

The socioeconomic factors to be considered include her source of income, health insurance, or the source of family’s financial support. EB has four antihypertensive prescription medications and it would be essential to assess her financial health and capability to afford these medications as needed. This consideration would be vital in discussing the patient’s medication adherence and compliance. Culture entails the religion, spiritual life and other aspects of people’s ways of life. Religion and spiritual life often impact one’s perception of health and treatment outcomes (Kennedy et al., 2017). In an attempt to ensure a culturally competent care, the clinician should establish EB’s religion and how the accompanying beliefs may impact her health seeking behavior. This would ensure that the EB has access to patient-centered care and that she is satisfied with the care plan, thus able to register improved quality of life.

Additionally, since EB is elderly and lives alone, it would be useful to assess her social environment and lifestyle for safety. The factors to include would be the social associations such as friends and social relationships. Besides, she is losing her vision over the past two years and may be at risk of injuries and assaults of various kinds. The relationships with the neighbors and extended family members could be a source of stress that would manifest with physical conditions that in turn contribute to the exacerbations of elevated blood pressure. Assessing the social relationships including family tree, presence and reasons for demise if any, and access to quality social support, would promote holistic care by enhancing her mental and physical health awareness.

Finally, the social lifestyle including use of recreational drugs, smoking, and alcohol would be important in assessing the non-pharmacological management of her hypertension (Dains, Baumann & Scheibel, 2019). She is a known hypertensive patient whose blood pressure on the day of clinic visit was very high. The reasons for the elevated blood pressure despite use of four antihypertensive medications should be established in her health history.

Sensitive Issues

The discussion with the patient would involve asking of questions to assess the patient’s personal life. Ideally, the questions should not offend the patient emotionally but provide meaningful health history. The sensitive issues that would be considered in this patient include alcohol use, use of recreational drugs, and concerns about whereabouts of other family members (Ball et al., 2019). The patient lives alone and the clinician may be interested in knowing the whereabouts of her family members for appropriate care considering her disabilities. The patient may not be using alcohol or any drugs and the question about drug use may upset her considering her age and gender, and unclear cultural background. As such, the clinician should reassure the patient about the purpose of the questions and keep the interview as modest as possible.

Targeted Questions

In an attempt to establish a more accurate health history, I would ask the patient the following five questions:

  1. How regularly do you take your medications?
  2. What is your religious heritage and has it helped you cope with your condition?
  3. Who do you talk to about your conditions back at home?
  4. Have you had any new symptoms or worsening related to your condition?
  5. Tell me more about your living situation.

Functional Assessment Case Study References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Kennedy, B. M., Rehman, M., Johnson, W. D., Magee, M. B., Leonard, R., & Katzmarzyk, P. T. (2017). Healthcare Providers versus Patients’ Understanding of Health Beliefs and Values. Patient Experience Journal, 4(3), 29–37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751953/