Assignment: Comprehensive Health History NURS 6512

Assignment: Comprehensive Health History NURS 6512

Being able to obtain a comprehensive health history for a patient is important in developing a treatment plan for them.  The purpose of this discussion post is to discuss interview techniques I would use for an 85-year-old white female living alone with declining health.  I will talk about the risk assessment instrument I would use and why.  Lastly, I will list five targeted questions I would ask to assess her health to start building a health history.

The first meeting with any patient is so important to build a good relationship and partnership from the start (Ball et al., 2019).  With this patient being 85 and living alone there will be a lot to consider when interviewing her.  I will need to establish is she is mentally with it, if she has hearing problems, and how much she understands about her health.  Older adults often assume certain problems are just normal parts of aging and not anything to be considered (Ball et al., 2019).  Often, older adults can also experience agism (Garrison-Diehn et al., 2022).  Even in health care settings older adults experience feelings of incompetence and being a burden (Garrison-Diehn et al., 2022).  It will be important to make sure she feels comfortable speaking to me knowing there is no bias or judgement.

The risk assessment I would do for this patient is the functional assessment.  This is an older lady who lives alone.  It will be essential to figure out how well she is able to function on her own.  One of the biggest risks for older patients is falling.  Falling is associated with adverse outcomes that can lead to a patient not being able to live at home anymore along with increased mortality (Snehal et al., 2020).  The functional assessment would give information regarding how well she can move around the house, is she is able to keep a clean environment, how meals are prepared, how she goes to the bathroom, and keeps good hygiene (Ball et al, 2019).  All these issues are going to contribute to her overall health.  It is important to gather this information to determine what assistance, if any, she will need.

After introducing myself and establishing how the patient would like to be addressed, I would start by simply asking “What brings you in today?”  This is a way to find out what her chief complaint is for coming in.  My second question would be “When did this start?”  This brings the patient back to the beginning and prompts them to tell the whole story regarding why they came in.  My third question would be “What medications do you take on a regular basis and what are they for?”  In my experience patients may or may not even know what they are taking, let alone why they are taking them.  It can also lead to her discussing if she is compliant with her medications.  To follow that, my fourth question would be “What medical problems do you have?”  Before going through a formal review of systems, this can give a clue to what she considers to be important in her history.   My last question would be “How well do you feel you are able to take care of yourself at home?”  This is an open-ended question to gain some insight on the functional assessment.  If the patient’s initial chief complaint is not urgent it is okay to give the patient some time while understanding the time constraints of you as the provider (Ball et al., 2019).

Establishing a relationship with patients and getting a thorough health history can be a daunting task for providers.  It is key to tailor interviewing skills to meet patient specific needs.  Modifying interview skills to the individual will eliminate communication barriers between the provider and patient (Bass et al., 2019).  Creating a strong relationship with the patient will allow the nurse practitioner to obtain the most comprehensive health history and provide the best possible care to clients.

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.

Garrison-Diehn, C., Rummel, C., Au, Y. H., & Scherer, K. (2022). Attitudes toward older adults and aging: A foundational geropsychology knowledge competency. Clinical Psychology: Science and Practice, 29(1), 4–15. https://doi.org/10.1037/cps0000043

Snehal, K., Rashmi, G., & Aarti, N. (2020). Risk factors for fear of falling in older adults in India. Journal of Public Health, 28(2), 123-129. doi:https://doi.org/10.1007/s10389-019-01061-9

This course is composed of four (4) separate modules. Each module consists of an overarching topic in which each week within the module includes specific subtopics for learning. As you work through each module, you will have an opportunity to draw upon the knowledge you gain in various Digital Clinical Experiences (DCE) and lab assignment components that will be due throughout each of the modules.

Module 1: Comprehensive Health History is a 1-week module, Week 1 of the course, in which you will examine how social determinants of health such as age, gender, ethnicity, and environmental situations impact the health and risk assessment of the patients you serve. You will also consider how social determinants of health influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.

What do I have to do?
When do I have to do it?
Review your Learning Resources
Days 1–7, Week 1
Discussion: Building a Comprehensive Health History
Post by Day 3 of Week 1, and respond to your colleagues by Day 6 of Week 1.
What’s Coming Up in Module 2: Looking Ahead
Review the “Looking Ahead” section for this week. You are encouraged to further review the requirements for the Shadow Health registration process for your digital clinical experiences.
Go to the Week’s Content

Week 1: Building a Comprehensive Health History

According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in the United States. One of the most admired nursing skills is the ability to put patients at ease. When patients enter into a healthcare setting, they are often apprehensive about sharing personal health information. Caring nurses can alleviate the hesitance of patients and encourage them to be forthcoming with this information.

The initial health history interview can be an excellent opportunity to develop supportive relationships between patients and nurses. Nurses may employ a variety of communication skills and interview techniques to foster strong bonds with patients and to effectively facilitate the diagnostic process. In conducting interviews, advanced practice nurses must also take into account a range of patient-specific factors that may impact the questions they ask, how they ask those questions, and their complete assessment of the patient’s health.

This week, you will consider how social determinants of health such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how social determinants of health influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.

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Learning Objectives

Students will:

Analyze communication techniques used to obtain patients’ health histories based upon social determinants of health
Analyze health-related risk
Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information

Learning Resources

Required Readings (click to expand/reduce)

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.

Chapter 1, “The History and Interviewing Process”
This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

Chapter 5, “Recording Information”
This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12.  https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x

Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508–513.

Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3.

Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical.

Chapter 2, “History Taking and the Medical Record” (pp. 15–33)

Required Media (click to expand/reduce)

Welcome and General Course Guidelines

Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

Module 1 Introduction

Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

Building a Comprehensive Health History – Week 1 (19m)

The interview focuses on constructing a comprehensive health history for a 4-year-old African-American male residing in a rural community. Effective communication strategies tailored to the patient’s age, ethnicity, and environmental context are crucial in gathering accurate information. Seidel et al. (2020) highlight that factors such as age, gender, race, and ecological setting significantly influence a patient’s health condition. To engage the 4-year-old patient, child-friendly communication techniques should be employed, including the use of age-appropriate language, active listening, and non-threatening body language, in addition to play-based interactions aided by toys or drawings, as suggested by Perry and Hockenberry (2021).

Tailoring questions to the patient’s social determinants of health is essential. Inquiring about daily routines, favorite foods, cultural practices, access to outdoor areas, and daily interactions helps gather pertinent information. Moreover, incorporating a risk assessment instrument specific to the patient’s circumstances is crucial. The Pediatric Environmental Health Toolkit’s (PEHT) questionnaire, as proposed by the Centers for Disease Control and Prevention (CDC), proves relevant in evaluating environmental factors that might affect the child’s health in a rural context.

The assessment of potential health risks considers the patient’s age-related developmental stage, potential exposure to agricultural chemicals and water contaminants in the rural setting, and the influence of his African-American ethnicity on genetic predispositions and cultural health practices. To foster effective communication and build trust, utilizing straightforward language, visual aids, and play-based communication methods is pivotal. Active listening and cultural sensitivity are foundational in addressing potential disparities in health beliefs and practices.

In conclusion, the PEHT questionnaire’s focus on environmental factors aligns with the patient’s rural living situation, making it an appropriate risk assessment tool. Through inquiries tailored to his context, such as outdoor activities, pet interactions, water quality, and exposure to local industries, the questionnaire assists in identifying potential health risks. These combined communication techniques and risk assessment strategies enable the nurse to construct a comprehensive health history for the 4-year-old patient, promoting effective care tailored to his unique needs and circumstances.

References:

Centers for Disease Control and Prevention. (n.d.). Pediatric Environmental Health Toolkit.

They were retrieved from https://www.cdc.gov/Links to an external site..

Perry, S. E., & Hockenberry, M. J. (2021). Wong’s Nursing Care of Infants and Children (11th

Ed.). Elsevier.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2020).

Seidel’s Guide to Physical Examination (9th ed.). Elsevier