Feb 23, 2024 NURS 6512 Building a Comprehensive Health History Essay
NURS 6512 Building a Comprehensive Health History Essay
NURS 6512 Building a Comprehensive Health History Essay
I enjoyed reading your post. I agree that an interview with an adolescent requires special techniques because it is a transitional stage of life between childhood and adulthood with various physical and psychological changes. Also, this is a period of change in their relationship with parents, peers, and other people around them as the adolescents become more independent (Trotman et al., 2018).
There are many subjects that may be of concern to adolescents. These include menstruation, appearance, sex, smoking, drugs, peer pressure, bullying, and thoughts of suicide (Ball et al., 2019). As you mentioned in your post, confidentiality is important for adolescents; otherwise, they may be reluctant to talk.
A conversation with a minor patient with UTI without insurance can be
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NURS 6512 Building a Comprehensive Health History Essay
challenging because we have to dig into his socio-economical/financial factor and the cause of his UTI. Adolescents may mumble or give one-word answers, such as “I don’t know” or “yes/no” to a healthcare provider. If they are in school, I may start the conversation by asking, “Which school do you go to?” “What grade are you in?” or “Which subject do you like the best at school?” before diving into health questions.
As Ball et al. (2019) suggest, open-end questions are good, but I would be a little more specific when I ask questions. For instance, instead of “How is school?”, I would ask “What do you like about your school?”. Opening lines of communication is difficult, especially with adolescents, and it may take time. But I believe that approaching in a non-judgemental way is an effective communication tool with adolescents.
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.
Trotman, G. E., Mackey, E., Tefera, E., & Gomez-Lobo, V. (2018). Comparison of Parental and Adolescent Views on the Confidential Interview and Adolescent Health Risk Behaviors within the Gynecologic Setting. Journal of Pediatric and Adolescent Gynecology, 31(5), 516–521. https://doi.org/10.1016/j.jpag.2018.03.006
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.
My assignment is based on working with an 85-year-old white female living alone with no family in declining health. While working on this task, I assume the patient is my mother, and I interrogate him with empathy, knowing that she is an elderly person who is likely to be more isolated and lonelier than individuals living with their loved ones. Here, I need to create an interviewing strategy to employ in assessing this patient’s medical condition, taking into account his advanced age that his health is declining.
Communication is a difficult endeavor that requires empathy and courtesy, especially when dealing with senior individuals. It’s critical to observe, listen, and gather information when pertinent information is offered when speaking with these kinds of patients. To preserve a constant pace with the patient, the medical practitioner not only should go slowly and be very patient (Ball et al., 2019).
Furthermore, by observing, the healthcare professional can connect to and be brought into the environment of the elderly. It is critical to comprehend the participant’s reality and the circumstances that may impact their responses. It’s critical for health care professionals to establish a good connection with patients in the interview session to create a favorable interaction.
The nurse tells the patient to introduce themselves to create familiarity and as the patient settles in the interview. Showing sincerity is vital while getting to know the social circle’s nature and the living condition of the patient. The questions could be personal, but they are meant to know the situation of the healthcare provider.
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://go.openathens.net/redirector/waldenu.edu?url=https://doi.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)
Assignment: Course Acknowledgement
This mandatory assignment is an acknowledgement that you fully understand the course guidelines.
By Day 3 of Week 1
Submit your Assignment.
Submission and Grading Information
Submit Your Assignment by Day 3 of Week 1.
To complete this assignment, follow the link below and answer the questions provided.
Week 1 Assignment
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Discussion: 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 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.
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.
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
What’s Coming Up in Module 2?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 2, you explore the impact of functional assessments, diversity, and sensitivity in conducting health assessments. You also examine various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.
Next week, you will specifically examine functional assessments as they relate to diversity and sensitivity
Registration for Shadow Health
Throughout this course, you will participate in digital clinical experiences using the online simulation tool Shadow Health. The Shadow Health digital clinical experience provides a dynamic, immersive experience designed to improve nursing skills and clinical reasoning through the examination of digital standardized patients. Using Shadow Health you will participate in health histories, focused exams, and a comprehensive assessment.
There will be four Shadow Health assessment components that you will need to complete in Module’s 2 and 3:
Health History Assessment (Week 3 & 4)
Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest pain
Comprehensive (Head-to-Toe) Physical Assessment (Week 9)
Before you can participate in these simulations, you will need to register for a Shadow Health account. To do this:
Go to the Walden Bookstore and purchase access to Shadow Health and the required texts.
Once Shadow Health has been purchased, an access code will be emailed to you from the bookstore.
Review this video explaining how to register in Shadow Health: https://vimeo.com/275921826/c12d50ee6e
Use the Shadow Health link located in the navigation menu on the left in the Blackboard course.
Follow the prompts to register in Shadow Health. You will need the access code provided from the bookstore to register. Once registered, Shadow Health should always be accessed via the link in Blackboard.
Use only Google Chrome when accessing Shadow Health and make sure all other programs are turned off on your computer. Other browsers do not work well and will not allow the Shadow Health speech to text function to work.
Once registered, complete the Shadow Health Orientation in the Shadow Health website/program and review the videos designed to assist with navigating and completing assignments.
Read the Shadow Health Nursing Documentation Tutorial located in the Week 1 Learning Resources.
Note: As nurses you typically use the word assessment to mean completing the physical exam. However, in the SOAP Note format, assessment means diagnosis so start getting in the habit of calling the physical exam exactly that.
Week 2 Case Studies
In Week 2, your Instructor will assign you a case study related to your Discussion by Day 1 of the week. Please make sure to review the “Course Announcements” area of the course to verify your assigned case study. Please plan ahead to ensure you have time to review your case study and your Learning Resources so that you can complete your Discussions and Assignments on time.
Photo Credit: Getty Images/iStockphoto
Practicum – Upcoming Deadline
In the Nurse Practitioner programs of study (FNP, AGACNP, AGPCNP, and PMHNP) you are required to take several practicum courses. If you plan on taking a practicum course within the next two terms, you will need to submit your application via Meditrek .
For information on the practicum application process and deadlines, please visit the Field Experience: College of Nursing: Application Process – Graduate web page.
Please take the time to review the Appropriate Preceptors and Field Sites for your courses.
Please take the time to review the practicum manuals, FAQs, Webinars and any required forms on the Field Experience: College of Nursing: Student Resources and Manuals web page.
Field Experience: College of Nursing Quick Answers
Field Experience: MSN Nurse Practitioner Practicum Manual
Student Practicum Resources: NP Student Orientation
Next Module
To go to the next module:
Module 2
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Thank you for your very informative and well-composed post. You did an excellent job of identifying highly pertinent questions necessary for an effective health history. I would like to suggest an additional assessment that I think would be extremely useful in this particular clinical case. This patient is a Native American living on a reservation, and a woman.
Unfortunately, this places her into a high risk category for domestic violence of all types, sexual assault, and likely lacking in resources to allow for safe and secure pregnancy and domesticity. Research indicates that Native American women are more likely to be victims of violent crime than any other demographic in the United States, and that 70% of sexual assaults on Native women go unreported, meaning that the number is likely much higher. Studies demonstrate that 70% of these violent crimes are perpetrated by persons of another race (not Native), also making Native women the largest target for interracial violent crime (Crossland et al., 2013).
It is imperative that advanced practice providers familiarize themselves with their patients’ cultural background and potential health risks that may be specific to that population, and that they screen their patients accordingly. The risk screening tool HITS would be an appropriate and effective tool in this clinical case. This assessment asks “In the past year, how often has your partner: Hurt you physically? Insult or talk down to you? Threaten you with physical harm? Scream or curse at you?” (Ball et al., 2019).
This assessment could be instrumental in protecting the health and safety of both the patient and her family, including her unborn child. The provider should also include in his health screening a physical assessment for indications of physical abuse, as with all other patients seen. Thank you again for your excellent post!
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.). Elsevier Mosby.
Crossland, C., Palmer, J., & Brooks, A. (2013). Nij’s program of research on violence against american indian and alaska native women. Violence Against Women, 19(6), 771–790. https://doi.org/10.1177/1077801213494706
To build a strong therapeutic relationship between the patient and the nurse, it is essential to obtain relevant and personal information about the patient by taking a thorough health history. According to the case study that was assigned, the 72-year-old man who was admitted to your Intensive care unit after having a severe stroke was rendered unconscious and unable to communicate. But, his wife claimed in an interview that they don’t have any advanced directives. But, she was certain that her husband would prefer not to live that way.
Their daughter, however, was convinced that her father would have preferred to be kept alive if there was a prospect for a positive outcome. The use of proper communication skills, such as the use of open-ended questions, active listening, empathy, and enabling the patient to only tell his tale once, will be required given the patient’s serious condition (Ball et al., 2019). The aforementioned communication strategies will enable the client to respond without becoming angry, frustrated, worn out, or bored.
The National Institutes of Health Stroke Scale (NIHSS) will be used because the patient has already experienced a severe stroke that has rendered him nonresponsive and unable to communicate. The scale evaluates hemi-inattention, extraocular motions, visual fields, limb strength, facial muscle function, sensory abilities, coordination, communication, and speech (Zöllner et al., 2020). The NIHSS is suitable for this patient because it will improve patient care by serving as an initial evaluation tool and by aiding in the planning of post-acute care disposition (Alkhouli & Friedman, 2019).
While the patient is unconscious, his wife will serve as the historian. The following specific inquiries will be displayed (Masci et al., 2019):
Could you explain your husband’s medical history?
What other medical conditions is your husband dealing with?
Does your husband currently take any medications?
Does anyone in the family experience comparable cardiovascular issues?
When was the last time your husband visited for a check-up or follow-up assessment?
References
Alkhouli, M., & Friedman, P. A. (2019). Ischemic Stroke Risk in Patients With Nonvalvular Atrial Fibrillation. Journal of the American College of Cardiology, 74(24), 3050–3065. https://doi.
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