Blog

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. Your instructor will assign you your case number.

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

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

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

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?

Cited in current APA style with support from at least 2 academic sources.

Cultural, Spiritual, Nutritional, & Mental Health Disorders

 Student’s Name

Institutional Affiliation

Course

Instructor’s Name

Date

Cultural, Spiritual, Nutritional, & Mental Health Disorders

Introduction

Building a health history is an important step in the treatment process. The health history of a patient involves inquiry into the patient’s family history, medical history, history of the patient, socioeconomic history, and others (Peate, 2019). Health history may be written in the subjective, objective, assessment, planning (SOAP) approach for documenting patient data (Peate, 2019). In that regard, this paper will use case study 1 to answer all the questions required to complete this assignment.

Patient’s History

The patient is an 86-year-old Asian male who walked to the hospital for his annual physical exam. Based on the information provided, the patient’s socioeconomic status is low. He is financially dependent on his daughter, who is also a single mother and has little money. Therefore, he is economically disadvantaged because he cannot afford to pay his medical bills (Peate, 2019). The information about the patient’s spiritual or religious status has not been provided. However, he looks like a good man who does not want to cause a financial burden to his daughter. The patient’s lifestyle does not seem healthy due to financial constraints (Peate, 2019). Although the daughter is trying to help the father live better, she is not able to provide everything required. However, the patient has a good habit of seeking timely medical advice and care in case of any health problem. He also maintains attending annual physical examinations to help him remain healthy.

The Subjective, Objective, Assessment, Planning (S.O.A.P.)

The Subjective, Objective, Assessment, and Plan (SOAP) approach is a widely used method for documenting a patient’s health data. This approach to the documentation of a patient’s health information is commonly known as the SOAP note (an acronym for subjective, objective, assessment, and plan) (Peate, 2019). The subjective information entails the patients feeling, experiences, or what they say about the problem. It includes chief complaint, history of present illness, and others. Objective information includes the therapist’s objective observations. They may include vital signs, physical exams, laboratory data, and imaging results. Assessment entails the therapist’s analysis of different components of the assessment (Peate, 2019). Finally, the plan represents how the treatment is going to be conducted to attain the treatment goals or objectives.

The Functional Anatomy and Physiology of a Psychiatric Mental Health Patient

The functional anatomy and physiology of a patient with major depressive disorder are a bit complex. Mental health such as depression can change the individual’s brain chemistry (Ancelin et al., 2019). Research by the National Institutes of Health showed that people with major depressive disorder lose grey matter volume leading to cognitive impairment. The loss of grey matter volume leads to the shrinking of several brain regions. Shrinkage is often seen in most depressed patients, especially in the hippocampus, thalamus, frontal cortex, and prefrontal cortex (Ancelin et al., 2019). These anatomical changes are characterized by a persistent depressed mood, alterations in motivation, pervasive feelings of guilt and worthlessness, and other depressive symptoms.

To assess specific functions, the nurse must first understand how the human body and mind function, the environment, and the health of the patient. Understanding the cognitive concept of a human being will help the nurse determine whether or not the patient has mental retardation (Ancelin et al., 2019). The environment will help determine the cause of such problems, and the patient’s health may show the severity of the problem. therefore, these are important concepts for any psychiatrist.

Conclusion

Health history is important to get a clear picture of a patient’s situation. It entails the patient’s family history, medical history, history of the patient, and others. The SOAP note is an effective way of documenting a patient’s health history. Mental health disorders such as major depressive disorder, are associated with changes in the function and anatomy of the brain.

References

Ancelin, M. L., Carrière, I., Artero, S., Maller, J., Meslin, C., Ritchie, K., … & Chaudieu, I. (2019). Lifetime major depression and grey-matter volume. Journal of psychiatry and neuroscience, 44(1), 45-53. https://doi.org/10.1503/jpn.180026

Peate. (2019). Fundamentals of assessment and care planning for nurses. John Wiley.