prenatal care

(ELIZABETH)

For this discussion I chose case 2, a 32-year-old pregnant lesbian who has not had complications up to this point. She is receiving prenatal care and received the sperm from a sperm bank. This is her first pregnancy. Today she is here for vaginal discharge. As a provider I need to realize her culture may be different than mine. This 32-year-old may have a harder time relating to others and her beliefs may differ. No longer is it acceptable to focus on a ‘typical family’ where a husband works and the wife stays home. Families now can be compromised of two males, two females, one male, one female, or one male and one female. I would first need to realize as a provider, I am not culturally competent to understand this patient’s beliefs or culture. Although I do not understand everything about this patient, I know to ask and provide unbiased review of her lifestyle. The first step to caring for her is to be culturally competent and sensitive to this patient (Ball et. al., 2015). I need to evaluate this patient as to what her lifestyle will be. Does she have a partner? Is her partner involved in this pregnancy? How does your family feel towards your pregnancy? Understanding adolescents who are less supervised are more at risk for depression, I want to establish her support system (Ball et. al., 2015). Is there any sexual abuse or have you experienced any in the past? With a history of ‘cutting,’ I need to know if there was any past or current abuse. I also want to know about her feelings. How do you feel about this pregnancy? Do you have any concerns with this pregnancy? Do you feel financially stable or do you need information on how to seek help? Finally once I have established how she feels about this pregnancy, I need to find out more about today’s problem.
Vaginal discharge could be an infectious process or a sexually transmitted disease (STD). When assessing the patient’s chief complaint, I would need to be very cautious of her lifestyle of homosexuality as to not offend her. Although she may be gay, a concern is of STD’s. I would need to ask if any past or current partners had any known STD’s or if she was concerned about STD’s. I would also need to assess her diabetic status as diabetes can be familial and diabetes could place her at increased risk for infection such as yeast. Yeast infections affect 3 out of 4 women in their lifetime and that risk increases during pregnancy due to hormones (Soong & Einarson, 2009). Lastly cultures would need to be done as well as blood work for diabetes, to establish if the vaginal discharge is normal for her pregnancy and to ensure she is not a diabetic as she has a strong family history. Diabetes is especially important as it can lead to loss of pregnancy, low birth weights, or altered wound healing (Damm et. al., 2014).
Questions:
Does she have a partner?
Is her partner involved in this pregnancy?
How does your family feel towards your pregnancy?
Is there any sexual abuse or have you experienced any in the past?
How do you feel about this pregnancy?
Do you have any concerns with this pregnancy?
Do you feel financially stable or do you need information on how to seek help?
Have you had gestational glucose testing yet? If not, any increased thirst or weakness?

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Damm, P., Mersebach, H., Råstam, J., Kaaja, R., Hod, M., McCance, D. R., & Mathiesen, E. R. (2014). Poor pregnancy outcome in women with type 1 diabetes is predicted by elevated HbA1c and spikes of high glucose values in the third trimester. The Journal Of Maternal-Fetal & Neonatal Medicine: The Official Journal Of The European Association Of Perinatal Medicine, The Federation Of Asia And Oceania Perinatal Societies, The International Society Of Perinatal Obstetricians, 27(2), 149-154. doi:10.3109/14767058.2013.806896
Soong, D., & Einarson, A. (2009). Vaginal yeast infections during pregnancy. Canadian Family Physician Médecin De Famille Canadien, 55(3), 255-256
Sullivan , D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

(CHARLES)
Cultural Factors
As clinicians, we will be faced with many challenges during our regular practice and cultural factors will be of prime consideration when dealing with clients from different cultures theirs as well as ours that may inhibit effective and satisfactory health care (Shaw, Huebner, Armin, Orzech, & Vivian, 2009). Also of vital importance, is the ability to identify our own limitations in knowledge and cultural perceptions and remain open to new perspectives or cultural humility (Ball, Dains, Flynn, Solomon, & Stewart, 2015) Case one is an at risk 86-year-old Asian male that is financially and physically dependent upon his daughter, who is a single mother, and doesn’t “want to be a burden to my daughter.” Many Asian cultures maintain a patriarchal or hierarchical family structure and according to Saccomano & Abbatiello (2014) this culture is focused on family decision making instead of individual decision making. Also according to Saccomano & Abbatiello (2014), the males in traditional Asian culture are the decision makers regarding treatment choices but, in this case, we find that it is his daughter that he is reliant upon.
Discrepancies
In his health interview and subsequent physical exam, it is noted that there is bruising in various stages of healing on his upper arms and back that may be related to his reported falls as well as his weight loss of 25 pounds over the past year. The bruising could be indicative of abuse or more falls than he is reporting. The key here is getting him to open up and talk about what has been happening to him. If his daughter is present, having her leave may assist in him opening up more with further questioning in regards to the discrepancies. Some Asian cultures will use more indirection or talk around the points or place more emphasis on feelings and attitudes (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Use of tools to screen for abuse has a valuable part to play in the clinical setting and can provide the framework for risk evaluation by implementing the three modes of screening, direct questioning, evident signs of abuse and risk indicators (Cohen, 2011). However, Cohen (2011) goes on to say that no research has explored the sensitivity of screening tools to cultural variances. Abuse is always a touchy subject and should be approached with care. The following questions may assist with clarifying the assessment.
Questions
1.How did you fall?
2.What lead up to you falling?
3.Do you feel safe in your home?
4.Do you get enough to eat?
5.Do you have three meals a day?
6.Do you take your medications regularly?
7.Do you prefer to stay home?
8.Do you feel satisfied with your life?
9.Do you have feelings of worthlessness?
10.Have you ever felt threatened at home?

References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination(8th ed.). St. Louis, MO: Elsevier Mosby.
Cohen, M. (2011). Screening tools for the identification of elder abuse. Journal Of Clinical Outcomes Management,18(6), 261-270 10p.
Saccomano, S. J., & Abbatiello, G. A. (2014). Cultural Considerations at the end of life. Nurse Practitioner, 39(2), 24-32 9p. doi:10.1097/01.NPR.0000441908.16901.2e
Shaw, S. J., Huebner, C., Armin, J., Orzech, K., & Vivian, J. (2009). The role of culture in health literacy and chronic disease screening and management. Journal of Immigrant & Minority Health, 11(6), 460–467.

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