NURS 6512 Week 1 Discussion

Building a Health History Discussion Assignment

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 one of the following new patients:

• 76-year-old Black/African-American male with disabilities living in an urban setting

• Adolescent Hispanic/Latino boy living in a middle-class suburb

• 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

ORDER NOW FOR AN ORIGINAL PAPER

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?
• 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.

By Day 3 of Building a Health History

Post a description of the interview and communication techniques you would use with your selected 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

Respond to at least two of your colleagues on two 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.

NURS 6512 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 health care 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 factors such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how these factors influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.

Learning Objectives

Students will:

• Analyze communication techniques used to obtain patients’ health histories based upon age, gender, ethnicity, or environmental setting
• Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information

Photo Credit: Hero Images/Hero Images/Getty Images

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Learning Resources

Required Readings

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

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.

• • 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.

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

• • Chapter 1, “Medicolegal Principles of Documentation” (pp. 1–14 and abbreviations, pp. 19)

• Chapter 2, “The Comprehensive History and Physical Exam” (pp. 23-32)

Note about Uploading Media:

Please refer to the Kaltura Media Uploader page located in the course navigation menu.. The documents on this page provide guidance on how to upload media for your Health Assessment Videos assignments for this course.

Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnen, V., L Van Abbema, D. & 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(30), 1–12. doi 10.1186/s12875-015-0241-x. Retrieved from http://bmcfampract.biomedcentral.com/articles/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. Post Grad Medical Journal, 91 (1079), 508–513. doi:10.1136/postgradmedj-2014-133195. Retrieved from http://pmj.bmj.com/content/91/1079/508

Lushniak, B. D. (2015). Surgeon General’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, 130(1), 3–5. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245280/

Jardim. T. V., Sousa, A., Povoa, T., Barroso, W., Chinem, B., Jardim, L., Bernardes, R., Coca, A., & Jardim, P. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Family Practice, 15(1111), 1–7. doi 10.1186/s12889-015-2477-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642770/

Optional Resources

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)

NURS 6512 Looking Ahead: Physical Health Assessment Videos

This course requires that you demonstrate proficiency in conducting physical health assessments, including a health history and a head-to-toe physical examination. You will demonstrate this proficiency by videotaping yourself as you perform the assessments. You will need to have access to a video recorder to capture the required physical health assessments on video. Additionally, you will need to obtain the necessary equipment required to perform these physical health assessments, including a stethoscope, an otoscope, an ophthalmoscope, a pocket eye chart, a tape measure, a reflex hammer and tuning forks (Frequency of 500-1000Hz to be used).  All of the required equipment must be used in order to pass the video and you must pass each video with a score >69.5% in order to pass the course.  You will also need to have a volunteer to act as your “patient” for each physical assessment. Your volunteer patient must be over 18 years of age, non-pregnant, and willing to be available for the entire video session. Each volunteer must sign the Video Release Form located on the Kaltura Media Uploader page located in the course navigation menu. The signed form must be faxed to the following toll-free number prior to recording each Video Assignment: 888–546–7564. Note: You may use the same volunteer for each video if appropriate.

Throughout this course, you will create and submit three physical health assessment videos.

Week 3: Health History

In Week 3, you will videotape yourself collecting a “patient’s” health history. This video is due by Day 7 of Week 4.

Week 8: Skin, Hair, and Nails and HEENT Assessment

By Day 7 of Week 8, you will create and submit a video of yourself conducting a Skin, Hair, and Nails and HEENT assessment

Week 10: Head-To-Toe Physical Assessment

By Day 7 of Week 10, you will create and submit a video of yourself conducting a head-to-toe physical exam.

Submitting Your Videos

All videos will be submitted through the weekly assignment submission area using the Kaltura Media option available via the mashup tool. Refer to the Kaltura Media Uploader page in the course navigation menu for more information about uploading media for assignments.

Note: Although you will only film and submit the health history, partial physical exam, and head-to-toe physical exam video assessments in Weeks 4, 8, and 10, respectively, it is highly recommended that you view each week’s media and practice performing the related health assessment on family members and/or patients. For example, in Week 7, you study the abdomen and gastrointestinal system. After watching the media assigned in that week’s Learning Resources, it is recommended that you practice conducting an abdominal examination.

To submit your completed Video Assignment(s), do the following:If you have not already done so, click on the Week 8 Assignment link. Once you have clicked on the link, click on the Write Submission button to turn on the Content Editor toolbar. Next, fill in the Submission field with any pertinent information. Attach your Assignment file by clicking on the Mashup button on the text editor menu bar and select Kaltura Media. Then find the media file you saved as “WK6Assgn+first initial+last name” and click on Open. Add any appropriate comments pertaining to your Assignment(s) in the Comments field. Be sure to attach all your video assignments. Finally, click on the Submit button to turn in your Assignment(s) for review.

For additional details on using the Kaltura Media mashup tool, please refer to the Kaltura Media Uploader page located in the course navigation menu.

SAMPLE APPROACH

Interview and Communication Techniques

During the interview of a 16-year-old white pregnant teenager living in an inner-city neighborhood, the techniques to build a health history should be thoughtfully and compassionately carried out.  Firstly, it is recommended during any interview that it take place in a comfortable setting.  It is advisable to stray away from equipment or desks/tables unintentionally creating a barrier between the provider and the patient.  The provider should sit eye level with the patient, relaxed, with a calm tone of voice.  These techniques will help the provider establish a relationship with the patient; gaining the patient’s trust, thus obtaining an accurate and thorough health history (Ball, Dains, Flynn, Solomon, & Stewart, 2015).

Secondly, the patient is an adolescent still.  When the provider introduces him/herself to the patient, anyone accompanying the patient should also be identified and addressed by name.  If there is a parent with the patient, the provider should learn the parent’s name and involve the parent.  However, a patient over the age of seven can typically be a dependable reporter for health information and the patient should be allowed confidentiality and privacy.  Adolescents may be reluctant to disclose certain information in front of a parent and wish to speak with the provider privately.  It is important to honor these wishes yet involve the parent and the patient’s support system in the patient’s care.  Despite the pregnancy, this patient still can struggle with normal adolescent behaviors and experiences in which risk factors such as poor self-esteem and peer pressure must also be recognized.  It is important to incorporate these techniques into practice so that these risk factors can be identified and help and prevention measures provided (Ball et al., 2015).

Thirdly, although an adolescent, this patient is pregnant.  Obtaining her health history regarding her pregnancy, any problems or complications thus far, menstrual and gynecologic history, and family history of genetic conditions or pregnancy related complications is vital.  This helps provide a direction for the appointment and future appointments, as well as identification of any health risks currently or potentially in the future (Ball et al., 2015).  Medical conditions such as diabetes or cardiac problems, risks for preterm labor, being pregnant with multiples, or any condition or issue which classifies the pregnancy as high risk, may prompt the need for a provider who cares for high-risk pregnancies (Fuentes, 2018).  Again, while obtaining her health history removal of any physical barriers such as electronic devices will help the patient feel more comfortable during the appointment, especially when talking about any sensitive issues or concerns (Ball et al., 2015).

Risk Assessment Tool

A risk assessment screening tool that could be utilized during the interview process with this patient would include the HITS screening tool for domestic violence.  The HITS screening tool includes questions for the patient, which asks if her partner has physically hurt her, insulted or belittled her, threatened her, or screamed at her in the past year (Ball et al., 2015).  As a 16-year-old, female gender, and pregnant, this patient is at an increased risk for intimate partner violence (IPV).  Intimate partner violence can have a significant consequence on an individual’s health.  These negative health risks can include chronic, acute, or fatal effects.  In regards to this particular patient’s pregnant health status, some negative health consequences can include an unintended or unwanted pregnancy, pregnancy complications, or miscarriage or abortion.  Additionally, this patient is at risk for sexually transmitted infections (STIs), sexual dysfunction, vaginal bleeding, vaginal or pelvic infections, multiple sexual partners, are at increased risk of having abusive partners in the future, and less likely to use contraception (World Health Organization, 2012).  It is imperative to ask questions when building a health history in order to assess the patient’s health risks.  Five questions that could be asked of this patient include:

• “Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?”
• “Do you feel safe at home or in your current relationship?”
• “Did you want to, or were you forced or talked into having sex?”
• “Is alcohol or drugs part of the problem?”
• “Has it gotten worse lately?”

Answering “yes” to any of these questions warrants further evaluation (Ball et al., 2015).

References

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s

guide to physical examination (8^th ed.). St. Louis, MO: Elsevier Mosby.

Fuentes, A. (2018). Medical care during pregnancy. KidsHealth. Retrieved from

https://kidshealth.org/en/parents/medical-care-pregnancy.html

World Health Organization. (2012). Understanding and addressing violence against

women: Health consequences. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/77431/WHO_RHR_12.43_eng.pdf;jsessionid=9B21862A7D4A6F36422173D14595A05E?sequence=1

NURS 6512 Week 1 Quiz

Question 1

Drawing of stick figures is most useful to:

Question 2

Mr. F. is speaking with you, the health care provider, about his respiratory problem. Mr. F. says, I ve had this cough for 3 days, and it s getting worse. You reply, Tell me more about your cough. Mr. F. states, I wish I could tell you more. That s why I m here. You tell me what s wrong! Which caregiver response would be most appropriate for enhancing communication?

Question 3

During the course of the interview you should:

Question 4

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

Question 5

Constitutional symptoms in the ROS refer to:

Question 6

A detailed description of the symptoms related to the chief complaint is presented in the:

Question 7

Which of the following is not a characteristic of the plan portion of the problem-oriented medical record?

Question 8

When recording assessments during the construction of the problem-oriented medical record, the examiner should:

Question 9

Mrs. G. reports an increase in her alcohol intake over the past 5 years. To screen her for problem drinking, you would use the:

Question 10

During a history-taking session, Mr. B. appears to be avoiding certain questions. He keeps looking out the window. What should the caregiver do?

Question 11

Mary Jane has brought in her 16-year-old son, Kyle. She states that he has been sleeping more, doesn t hang around his friends, and recently his girlfriend broke up with him. Your most immediate question is to ask Kyle:

Question 12

You are collecting a history from an 11-year-old girl. Her mother is sitting next to her in the examination room. When collecting history from older children or adolescents, they should be:

Question 13

J.M. has been seen in your clinic for 5 years. She presents today with signs and symptoms of acute sinusitis. The type of history that is warranted is a(n) _____ history.

Question 14

A tool used to screen adolescents for alcoholism is the:

Question 15

Ms. S. reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S. s loss of appetite, it would be better to:

Question 16

Subjective and symptomatic data are:

Question 17

Which of the following is an effective adjunct to document location of findings during recording of physical examinations?

Question 18

When taking a history, you should:

Question 19

Which question would be considered a leading question?

Question 20

Which of the following is considered an IADL but not an ADL?