Nursing Assignment: Building A Health History
Nursing Assignment: Building A Health History
A sample Answer For the Assignment: Nursing Assignment: Building A Health History
Building a Health History
Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following new patients:
Having Trouble Meeting Your Deadline?
Get your assignment on Nursing Assignment: Building A Health History completed on time. avoid delay and – ORDER NOW
· 76-year-old Black/African-American male with disabilities living in an urban setting
· Adolescent Hispanic/Latino boy living in a middle-class suburb
Struggling to Meet Your Deadline?
Get your assignment on Nursing Assignment: Building A Health History done on time by medical experts. Don’t wait – ORDER NOW!
· 55-year-old Asian female living in a high-density poverty housing complex
· Pre-school aged white female living in a rural community
· 16-year-old white pregnant teenager living in an inner-city neighborhood
To prepare:
With the information presented in Chapter 1 in mind, consider the following:
· How would your communication and interview techniques for building a health history differ with each patient?
· How might you target your questions for building a health history based on the patient’s age, gender, ethnicity, or environment?
· What risk assessment instruments would be appropriate to use with each patient?
Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS Nursing Assignment: Building A Health History:
· What questions would you ask each patient to assess his or her health risks?
· Select one patient from the list above on which to focus for this Discussion.
· Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
· Select one of the risk assessment instruments presented in Chapter 1 or Chapter 26 of the course text, or another tool with which you are familiar, related to your selected patient.
· Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
Questions to be addressed in my paper:
1. A description of the interview and communication techniques you would use with your selected patient.
2. Explain why you would use these techniques.
3. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient.
4. Provide at least five targeted questions you would ask the patient.
5. Summary with Conclusion
REMINDERS:
1) 2-3 pages (addressing the 5 questions above excluding the title page and reference page).
2) Kindly follow APA format for the citation and references! References should be between the period of 2011 and 2016. Please utilize the references at least three below as much as possible and the rest from yours.
3) Make headings for each question.
References:
Readings
· 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.
o Chapter 1, “The History and Interviewing Process” (pp. 1–21)
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.
o Chapter 26, “Recording Information” (pp. 616–631)
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. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 1, “Medicolegal Principles of Documentation” (pp. 1–12 and abbreviations, pp. 18)
o Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–36)
·Deeks, A., Lombard, C., Michelmore, J., & Teede, H. (2009). The effects of gender and age on health related behaviors. BMC Public Health, 9, 213–220.
Retrieved from the Walden Library databases.
This article describes a study that sought to determine the effects of gender and age on health-related behaviors. In the study, the authors also investigated the effects of screening practices, health beliefs, and perceived future health needs.
· Delpierre, C., Lauwers-Cances, V., Datta, G. D., Berkman, L., & Lang, T. (2009). Impact of social position on the effect of cardiovascular risk factors on self-rated health. American Journal of Public Health, 99(7), 1278–1284.
Retrieved from the Walden Library databases.
This study assessed the influence of education level on the association between self-rated health and cardiovascular risk factors. The authors explain their methods and results, and they provide recommendations for similar studies in different countries and cultures.
· Lee, D. W., Neumann, P. J., & Rizzo, J. A. (2010). Understanding the medical and nonmedical value of diagnostic testing. Value in Health, 13(2), 310–314.
Retrieved from the Walden Library databases.
The authors of this article detail their attempts to develop a framework for defining the potential value of diagnostic testing. The authors also discuss the implications of their framework for health care delivery systems.
· University of Michigan Medical School. (2003). Geriatric functional assessment.
Retrieved from http://www.med.umich.edu/lrc/coursepages/m1/HGD/GeriatricFunctionalAssess.pdf
This article provides an exercise that emphasizes accurate functional status assessments and effective communication with older patients. The authors recommend tools and techniques to be used when caring for older patients.
Optional Resources
· LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw- Hill Medical.
o Chapter 2, “History Taking and the Medical Record” (pp. 15–33)
As an advanced practitioner, it is imperative to build a therapeutic relationship
with the patient to obtain the most and accurate health history of that specific patient; the medical history is a crucial information in developing an appropriate plan of care for that patient. Each patient may require different communication techniques and considerations based on their social determinants of health and health risks. In this week’s discussion, I am presented with an adolescent white male that is without health insurance and seeking medical care for a sexually transmitted infection. The purpose of this discussion is to examine communication techniques specific to my patient and at least five targeted questions to assess the health risks and building of patient’s health history.
Health History Interview
Since the patient is an adolescent male that presents with STI, my priorities would be identifying high risk behaviors such as use of illicit drugs and alcohol, risky sexual behaviors, and suicidal ideations. According to Johnston et al. (2022), data from 184 countries in nine UNICEF regions suggested that there are approximately 17 million adolescent young men who are bisexual and sell sex that needs HIV prevention services and social support. In addition, America Foundation for Suicide Prevention (2022) stated that 8.9% of youth grades 9-12 reported having at least one suicide attempt within 12 months. Therefore, my targeted questions would include:
-
- Do you smoke or drink? If so, how many times a week?
- What is your sexual orientation? (ex. heterosexual, bisexual, etc.)
- Do you use any illicit recreational drugs?
- How many sexual partners have you had in the last month?
- Have you ever had suicidal ideations or attempts?
Communication Techniques
There are many barriers in obtaining accurate and sufficient health history; in my patient’s case, he is an adolescent teen who may be hesitant to tell the honest answer when it comes to sensitive subjects such as alcohol, recreational drug use, or sexual orientation. Many adolescents are exploring to find self-identity during this time and unfortunately, it often involves high-risk behaviors.
Mental health has been more recognized in the last decade, and suicidal ideation awareness and assessment has been more widely adopted in healthcare settings. Ball et al. (2019) stated that when discussing sensitive issues, there are many essential considerations during the interview such as providing privacy, being direct and firm by avoiding leading questions, not apologizing for asking a question, not being judgmental or pushy, and using language that is understandable but not patronizing.
First impression is a big factor when introducing yourself to the patient; for this patient, I would try to initially relate to the patient by talking about common hobbies that can relate to adolescents such as games or sports and build a trusting relationship. I would be firm in saying that you need to tell me the truth about alcohol or drug use, but that the information would stay confidential, and I will not purposely expose information that would get the patient in trouble with his guardians or with the law.
One assessment tool that can be used for my patient that would help with obtaining health history is the ‘CRAFFT’ questionnaire. It was developed in 2002 as a screening tool for alcohol and substance abuse in adolescents; a two or more (2 to 6) yes answers suggests a serious substance use disorder problem and the questionnaire also recommends counseling regarding many aspects such as reviewing the screening results, recommending not to use such drugs, driving risk counseling, eliciting self-motivational statements, and reinforcing self-efficacy (New Jersey Chapter: American Academy of Pediatrics, 2018). This assessment tool is important because the patient’s social background and high-risk behaviors may be correlated with patient’s sexual behaviors that led to patient having an STI.
Conclusion
Obtaining patient’s health history takes more than just interviewing the patient; it takes a lot of effort in building a trusting relationship and understanding their personal situation and poor social determinants of health such as poverty or no insurance that is constant even after they are discharged from the healthcare setting. Assessing each patient with individualized plan of care and applying the correct communication techniques that apply to different age groups/gender/ethnicity are key in building a therapeutic relationship with the patient that will yield in better health outcome.
References
American Foundation for Suicide Prevention. (2022). Suicide statistics. Retrieved November 29, 2022 from https://afsp.org/suicide-
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.
Johnston, L., Nguyen, V., Lwamba, C., Sabin, K. (2022). Deriving and interpreting population size estimates for adolescent and young key populations at higher risk of HIV transmission: Men who have sex with men and females who sell sex. PLoS One, 17(9). https://doi.org/10.1371/
New Jersey Chapter: American Academy of Pediatrics. (2018). The CRAFFT Questionnaire (version 2.1). https://njaap.org/wp-content/
Sarkisian, K., Planalp, E., Carol, V. H., & Goldsmith, H. H. (2022). Leveraging latent profile analysis to synthesize childhood and adolescent risk factors for suicidal ideation. PLoS One, 17(8). https://doi.org/10.1371/