Feb 23, 2024 Discussion: Building a Health History
Discussion: Building a Health History
Discussion: Building a Health History
Effective communication during an advanced clinical assessment is a key factor that builds the patient-practitioner relationship, improves patient satisfaction, and increases compliance with the care plan. Developing trust and understanding during the clinical interview and examination will encourage the disclosure of additional information vital to the patient’s care, ensure the patient is in control of their treatment goals – and make them realistic, leading to more accurate diagnoses and care initiatives (Diamond-Fox, 2021). A well-developed health history includes social determinants of health (SDOH), which can help determine the level of capacity and motivation the patient will use to follow through with the developed treatment plan (Naseh et al., 2023).
This discussion post aims to explain the social determinants of health (SDOH) a patient may face living at home with declining health. The discussion will identify specific questions and techniques used during an advanced clinical assessment to identify risks the patient may be encountering in the home. It will explain how to utilize risk assessments to positively impact the health status of an eighty-five-year-old community-dwelling female who has no support and health is declining.
Social Determinants of Health (SDOH)
SDOH can help guide the practitioner toward the appropriate individualized care plan. The health-related social needs are addressed through conversations about food security, housing, and transportation to meet the specific demands needed to improve the quality of patient care. The practitioner notes that an 85-year-old female is living at home and may not be able to cook or care for herself adequately and may be dealing with the struggles silently.
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In addition, if the patient were to need hearing aids to prevent falls, the practitioner would be helpful in writing referrals to hearing providers (Riska et al., 2021). The information the practitioner gathers in the health history is vital to ensure the safety of the patient, to prevent chronic disease (e.g., diabetes), and to determine community support the patient may not be aware is available. All must be considered during the interview process (Naseh et al., 2023)
The Interview
To begin the interview process, the practitioner will ensure the patient’s comfort and sit at eye level to avoid discomfort and ensure the patient cannot see and hear the practitioner without difficulty. The practitioner notes that questions asked to the 85-year-old patient may need to be spoken to in a loud, plain, and slow manner to ensure the patient adequately understands the interview questions. It is essential to avoid rushing or appearing impatient by allowing time between questions for the patient to answer to avoid overlap and confusion. With good eye contact, the practitioner should speak directly to the patient in a mature tone and remember that physical, sensory, and cognitive deficits should not dissuade the patient’s interaction or perceived decision-making capacity.
The practitioner should take the time to note any cultural differences that may affect the ease of dialogue and communicate the inquiry professionally to ensure the patient’s participation, opinion, and expectation of the interaction are known before the interview begins. Even though the patient is white, it does not mean they do not have a cultural or language barrier to consider (Diamond-Fox, 2021).
The interview process is used to build rapport and gain insight into the overall safety and functional ability of the aging community-dwelling patient (Diamond-Fox, 2021). The practitioner may begin by asking the patient open-ended questions that guide the interview process. One of the first questions a practitioner should ask is 1) “Can you see and hear me now without difficulty?” to gauge sensory deficits that may prevent adequate communication and understanding in the clinic today and in the community setting. Ensuring that the patient is alert and oriented is crucial, so the practitioner should verify the appointment date, time, and place. It is an excellent time to introduce and meet the caregiver (if applicable) in the room.
A caregiver who is not related to the patient may be present with a geriatric patient –and the practitioner should take great care to ensure the patient is at the center of the interview and interact directly with the patient (versus the caregiver) during the interview process. If a caregiver is absent, the practitioner should use the moment to inquire about emergency contact, family, and friends. A social worker is a helpful addition to the patient’s team if the patient does not have friends or family. It may be helpful to present an overview and timeline of the interview to address toileting needs.
During the interview, the practitioner should take great care to notify the patient when the subject changes to avoid confusion. The practitioner should ask prompting questions to address the main concern today, like 2) “Can you tell me what bothers you the most today (e.g., pain, aches, area of concern)?” and start to build from the question to gain insight into ailment or a pain concern. Exercise and activity level will be vital to possible therapy or treatment orders that may be needed. The practitioner should consider subjective and objective data during the response and watch for the response to become a focused problem that elicits immediate attention – the practitioner should adjust and follow the problem based on the need (Ball et al., 2022, p. 34).
Once initial concerns are addressed, the practitioner should begin the health history and take time to integrate the necessary risk assessment tools available to assess and discover needs. Risk assessments help identify if the patient qualifies for an assistance program or needs increased care. Several signs guide a practitioner to the decision of the advanced level of care, including 1) nutritional decline, 2) increase in falls or physical injuries, and 3) decline in personal hygiene (e.g., malodorous, dirty clothing, incontinence, skin breakdown). The practitioner should begin the conversation with 3) “Have you fallen in the last few days, months, or years?” The practitioner should consider the use of a tool called Lawton’s Instrumental Activities of Daily Living Scale (IADL) to assess eight (8) categories of functions the patient needs to live independently (Thomas, 2023).
The practitioner will perform the evidence based IADL, which provides a systematic approach to the dimensions of ADLs, including the use of the telephone, shopping, food preparation (e.g., assessing for signs of malnutrition), housekeeping, laundry, transportation, medication responsibility, and finances. The goal during the specific IADL interview is to discover how the patient functions in the home, giving the option to give specific information. It is important to avoid being judgmental and ask questions to gain trust and guide further understanding (APA, 2023).
The practitioner may consider the patient’s spirituality by asking 4) “Can you tell me about your spirituality or faith?” as the question and then related questions may guide the social aspect of their life (e.g., marriage, recent deaths, church or support group attendance). It will also be a good lead into using home remedies, supplements, and other cultural-based treatment methods the patient uses in the home. The practitioner can use the subject of spirituality as a springboard to a more focused suicide screening called the Columbia Suicide Severity Rating Scale (C-SSRS). The evidence-based scale includes a series of pointed questions that assess the severity and immediate risk for suicide (SAMHSA, n.d.).
It should be said that before each transition to the next topic, it is an optimal time to offer education, correct myths or misconceptions, provide handouts, and plan to guide available services and community-led partners that offer language and culturally appropriate services. The goal of the interaction is to choose interventions and prevention strategies that help the patient overcome obstacles they are facing and ensure their safety in the home and community. Lastly, it is imperative to ensure that the patient’s interview expectations were met and that specific topics the patient wanted to discuss were included.
A good question to start closing the conversation is 5) Did I answer all your questions today?” paired with good eye contact and full attention before wrapping up the conversation. The practitioner should be ready for additional topics or questions to arise as the interview ends and will obtain a good understanding of the patient’s perception of the interview. The practitioner should review the information before leaving the room, as the goal is to provide a seamless and professional exit from the room (Diamond-Fox, 2021).
Conclusion
While performing an advanced clinical assessment for an 84-year-old community-dwelling female with declining health, the practitioner will utilize appropriate evidence-based risk assessments (e.g., fall risk assessment, IADL, C-SSRS) to guide intervention and prevention strategies to keep the patient safe. The practitioner will utilize a series of interview questions to guide the interaction towards SDOH that may be creating difficulty for the patient to safely continue living at home. Lastly, the reader will understand how to assess the patient’s overall cognitive, sensory, and functional ability and ensure appropriate intervention and prevention strategies are used when interacting with a geriatric patient.
Thank you,
Jacey Benson, PMHNP Student
References
American Psychological Association (APA). (2023). Instrumental activities of daily living scale. American Psychological Association. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools
Links to an external site.
Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2022). Chapter 2: The history and interviewing process. In Seidel’s guide to physical examination: An interprofessional approach (mosby’s guide to physical examination) (10th ed., pp. 12–34). Elsevier.
Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238
Links to an external site.
Naseh, M., Zeng, Y., Rai, A., Sutherland, I., & Yoon, H. (2023). Migration integration policies as social determinants of health for highly educated immigrants in the united states. BMC Public Health, 23(1). https://doi.org/10.1186/s12889-023-16254-x
Links to an external site.
Riska, K., Peskoe, S., Gordee, A., Kuchibhatla, M., & Smith, S. (2021). Preliminary evidence on the impact of hearing aid use on falls risk in individuals with self-reported hearing loss. American Journal of Audiology, 30(2), 376–384. https://doi.org/10.1044/2021_aja-20-00179
Links to an external site.
Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Columbia suicide severity rating scale (C-SSRS). USA.gov. https://www.samhsa.gov/resource/dbhis/columbia-suicide-severity-rating-scale-c-ssrs
Links to an external site.
Thomas, L. (2023). Assessing activities of daily living (ADLs), instrumental activities of daily living (IADLs), and functional status. Journal of Life Care Planning, 21(2), 37–56. https://eds.s.ebscohost.com/eds/pdfviewer/pdfviewer?vid=7&sid=d238108c-6f18-4076-9c2e-21322d2e8556%40redis
Adolescent white male without health insurance seeking medical care for STI.With every patient being unique in their own way makes communication strategiesdifferent as well. Knowing that individual illness is influenced by factors like age,gender, ethnicity and environmental settings calls for a provider to be sensitive tothese aspects. (Ball, et, al 2019). With my patient being adolescent white malewithout health insurance seeking medical care for STI calls for my attention inbuilding a trust from my patient so that I can determine the best way to treat him.
This will be achieved by exploring his concerns, exploring the expectation of hisencounter in terms of treatment and how confidential his visits will be kept. Alsoidentifying any underlying worries that he might have will be explored by asking himif the answers and mode of treatment were satisfactory and if there were any otherareas that he wanted to explore in detail which could be how does one get STD andways to avoid contracting STDs.
With this visit, chances to provide education about STD will be provided which willbegin by emphasizing to this patient that our conversation will be kept confidential. Iwill be keen to notice any body language gestures or any hesitancy to answerquestions as I should be aware according to (Liu, et, al, 2022) that there will beoccasions that I will experience silence and at times sheepish conversations mightprevail during the visit.
The risk assessment instrument that will be used with my patient’s scenario is thefive Ps of sexual history. According to (Ball, et, al, 2019) the five Ps stands forpartners, practices, protection from STIs, past history of STIs and prevention.Some of the health-related risks based on this patient’s age group and genderaccording to (Widman, et, al 2018) could be peer pressure, poor schoolperformance, nonparticipation in school extracurricular activities like sports andfinally susceptibility to the internet and social media during and after school whichcould be the reason why the patient contracted STD.
Some of the questions that will be asked to assess his health risk according to (Ball,et, al,2019) include number and variety of partners, protections used against STI,sexually transmitted disease history, STI knowledge, their feelings and thought aftergetting STD, how many sexual partners have you had so far, how did you feel afterfinding out you had STD? what measures are you thinking that will help you inreducing chances of getting STD in the future, does your partner know that she/hehas STD? if so has she had treatment? Future safer sex practices.
Reference,
Liu, H., Ke, W., Chen, H., Liang, C., & Yang, L. (2022). The perceptions of sexualityand sexually transmitted diseases (STDs) among adolescent STD patients: A
qualitative study. Journal of Pediatric Nursing, 66,e54–e60. https://doi.org/10.1016/j.pedn.2022.05.018
Links to an external site.Widman, L., Golin, C. E., Kamke, K., Burnette, J. L., & Prinstein, M. J. (2018).Sexual Assertiveness Skills and Sexual Decision-Making in Adolescent Girls:Randomized Controlled Trial of an Online Program. American Journal of PublicHealth, 108(1), 96–102. https://doi.org/10.2105/AJPH.2017.304106Links to anexternal site.Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019).In Seidel's Guide to Physical Examination: An interprofessional approach (pp. 7–19).essay, Mosby.
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.
Click here to ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Discussion: Building a Health History
For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To prepare:
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
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 social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
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 5 of the Seidel’s Guide to Physical Examination 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.
By Day 3 of Week 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
The case concerns an adolescent Hispanic/Latino boy living in a middle-class suburb. When interviewing this client, I would ask about his health concerns, including his primary reason for the visit. During the interview, I would ask the client about his health prevention and promotion activities, sexual activity, and mental health issues. I would be warm and friendly to the client, shake his hand, and make eye contact. I would also reassure the patient about the confidentiality of the information he provides (Takeuchi et al., 2021). This will help the client feel comfortable and encourage him to convey his health concerns. Furthermore, I will express interest in the client’s life, not just his medical concerns.
Effective communication techniques are crucial in eliciting information from adolescents. When discussing sexual activity, I will introduce the questions about sexual activity comfortably. If the patient expresses confusion about sexual activity, the nurse will clarify for him (Savoy et al., 2020). In addition, I will ask appropriate questions, even though the patient and I are uncomfortable. I will also acknowledge the awkwardness of the questions and normalize it by mentioning that I ask all adolescent clients these questions (Shafii et al., 2019). Furthermore, I will articulate to the client the patient’s need to be listened to and make him not feel pressured into disclosing his feelings. I would also use humor to empathize with the client, which will help get a positive response from him.
The CRAFFT questionnaire can be used for this client. It is used to screen for alcohol and substance abuse in adolescents (Ball et al., 2019). It is ideal for this patient since he is an adolescent living in a middle-class suburb, which usually has a high prevalence of adolescent alcohol and substance abuse.
Target Questions
What health concerns do you have today?
Other than health issues, what social or psychological problems are you experiencing?
What factors often make you psychologically distressed?
How is your relationship with your peers in school and at home?
What is your sexual preference?
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.
Savoy, M., O’Gurek, D., & Brown-James, A. (2020). Sexual health history: techniques and tips. American Family Physician, 101(5), 286–293.
Shafii, T., Benson, S. K., & Morrison, D. M. (2019). Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study. Journal of medical Internet research, 21(7), e13220. https://doi.org/10.2196/13220
Takeuchi, Y. L., Bonvin, R., & Ambresin, A. E. (2021). ‘Demystifying’ the encounter with adolescent patients: a qualitative study on medical students’ experiences and perspectives during training with adolescent simulated patients. Medical education online, 26(1), 1979445. https://doi.org/10.1080/10872981.2021.1979445
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:
Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.
This is an informative post. Building a rapport with the patient is one of the communication skills that help to attain trust when interviewing patients. In addition to the distinctive approaches mentioned, HEADSS is another risk assessment measure for this adolescent boy from a middle-class suburb. For this high-risk demographic, this tool addresses home, education, activities, drugs, sex, and suicide (Sturrock & Steinbeck, 2019). This tool helps to obtain answers on who lives with them and their connection with them. Questions about his education will help identify a drop in school achievement and their overall experience.
Adolescents with body image problems tend to withdraw from association with peers, hobbies, and extracurricular activities, leading to depression and suicide; therefore, addressing one’s eating habits and researching current weight or appetite changes might reveal more about one’s body image problems. If the patient reports bad moods, withdraws from friends and family, and mentions hurting oneself, suicide should be considered (Sturrock & Steinbeck, 2019). Finally, sexually transmitted illnesses might be indicated by sexual activity.
Additionally, maintaining confidentiality is crucial. The teenager should be offered the option of having parents or loved ones present throughout the interview. Involving family members before the evaluation may assist in acquiring their and the teenager’s trust (Barzin, 2018). However, parents or loved ones should be gently requested to depart after an initial acquaintance. Lastly, allowing the boy to ask questions after the interview will make him comfortable, allow the practitioner to address any concerns, clear up doubts, and help build a solid rapport.
References
Barzin, A. (2018). Chronic illness care: Principles and practice. Chapel Hill, NC: Springer.
Sturrock, T., & Steinbeck, K. (2019). Adolescents and youth in adult hospitals: psychosocial assessment on admission – an evaluation of the youth care plan. Australian Journal of Advanced Nursing, 31(1), 28-35. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspxLinks to an external site.? direct=true&db=edswsc&AN=000329977900004&site=eds-live&scope=site
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion
Developing or building an accurate and detailed patient history is a cornerstone of initiating an appropriate plan of care for any patient and is a skill that is essential for the APRN. In this way, we get to know our patient’s, their past concerns and issues, and how past problems impact current functioning. A complete health history is also necessary when collaborating with other healthcare clinicians or when there is a transfer of care.
Factors such as age, gender, ethnicity, and living environment all should be
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