NURS 6512 week 1 Building a Comprehensive Health History examples
Building a Comprehensive Health History
My post this week concerns a 76-year-old African American male with disabilities living in an urban setting. I will refer to him as Mr. B.
Interview and Communication Techniques
The appointment will start with the use of open-ended questions, such as “How are you feeling today?” and “What concerns or symptoms would you like to discuss in today’s appointment?” I would also ask Mr. B to relate his understanding of his disabilities and any health problems, as well as how he manages them. Open-ended questions encourages the patient to talk to the provider and not answer “yes” or “no.” I will get a feel for how well Mr. B understands his health issues and if they are being managed correctly. NURS 6512 week 1 Building a Comprehensive Health History examples.
The next step is to ask direct questions. This will give me specific information, such as the exact location of pain, when issues first started, and/or dosing instructions of current medications. After I have gathered all the necessary information from Mr. B, I will interpret what has been said. Ball, Dains, Flynn, Solomon, and Stewart (2015) state that to interpret is to repeat what you have heard to confirm the patient’s meaning. Next, I will ask Mr. B about his life situation NURS 6512 week 1 Building a Comprehensive Health History examples. I can establish if there are any unmet needs at home. This topic will be discussed further in the next section.
At the conclusion of the visit, I will reiterate what has been discussed during the appointment. I will express any need for further treatments or office visits. The last thing to do is find out if Mr. B’s expectations of the appointment have been met and if he has any further questions.
Numerous screening instruments have been developed to detect common geriatric problems (Sullivan 2012). The Katz Index of ADLs (activities of daily living) and Lawton IADL (instrumental activities of daily living) Scale are examples of tools used to screen a patient’s functional ability. The Katz Index addresses specific ADLs, such as bathing, dressing, toileting, transferring, continence, and feeding. NURS 6512 week 1 Building a Comprehensive Health History examples The Lawton Scale scores points on functionality in other areas, such as the ability to use a telephone, shopping, laundry, mode of transportation, food preparation, housekeeping, responsibility for own medications, and the ability to handle finances. According to Deck et al. (2015), the rationale behind a geriatric assessment is to assess how illness impacts functioning and what the social and medical needs are in order to develop a plan for treatment and follow-up, to manage the problems that were identified, and to prevent dependency. Five essential questions to ask are:
- Can you perform basic ADLs? (as listed in the Katz Index of ADLs).
- Do you live alone? If yes, do you have family and friends who can help in times of need?
- Do you feel safe in your home and neighborhood?
- Can you afford all your expenses, especially medication?
- Are you able to prepare meals or have someone prepare them for you?
Older adults are a vulnerable population. People try to take advantage of them. They do not always provide accurate information to their healthcare provider for a variety of reasons. Healthcare providers need to spend extra time with older adults to get to the root of problems. NURS 6512 week 1 Building a Comprehensive Health History examples
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.
Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnen, V., …
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
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA:
- A. Davis. NURS 6512 week 1 Building a Comprehensive Health History examples
Excellent post on the assessment of building health information for the practitioner. I was appreciative of the way Wu and Orlando said the risk assessment should be addressed. Health risk assessments provide an opportunity to emphasize health promotion and disease prevention for individuals and populations at large (Wu & Orlando, 2015). Do you think that Mr. B will be receptive to the emphasis of health promotion and disease prevention? In a study on nutrition Hu et al., performed long-term, periodically collected dietary data in the NHS, with documented reliability and validity, have contributed extensively to our understanding of the dietary determinants of various diseases, informing dietary guidelines and shaping nutritional policy (2016) NURS 6512 week 1 Building a Comprehensive Health History examples. In this instance the guide lines can prevent issues from malnutrition and with a reliable data base can increase ability to prevent disease.
Hu, F. B., Satija, A., Rimm, E. B., Spiegelman, D., Sampson, L., Rosner, B., … & Willett, W. C.
(2016). Diet assessment methods in the Nurses’ Health Studies and contribution to
evidence- based nutritional policies and guidelines. American journal of public health, 106
(9), 1567-1572. NURS 6512 week 1 Building a Comprehensive Health History examples
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family
health history: barriers and benefits. Postgraduate medical journal, postgradmedj-2014
Building a Comprehensive Health History
NURS 6512: Advanced Health Assessment and Diagnosis Reasoning
Building a Comprehensive Health History
Upon establishing a relationship and building a comprehensive health history, one must understand the importance of a thorough history document. This document is often used as the basis for the entire course of medical management for a patient (Sullivan, 2012) NURS 6512 week 1 Building a Comprehensive Health History examples. Everyone has a story, and the heath history document should paint an up-to-date and accurate account of the patient’s medical history and a comprehensive physical examination. Any professional that reads the health history document should have a good overview of that patient. According to Ball, Dains, Flynn, Solomon, & Stewart (2015), the initial meeting between the clinician and the patient sets the tone in the relationship for success, allows the patient to voice concerns, identifies expectations for a good outcome, and to build a partnership in one’s health care. For this week’s discussion, the role of a clinician when building a comprehensive health history with a 16-year old white pregnant teenager living in an inner- city neighborhood will be identified. In addition, review of communication techniques and a risk assessment tool is used with five or more targeted questions that could be asked in this particular situation.
Interview and Communication Techniques
Adolescents is a time between childhood and adulthood where risky behaviors are experimented and where privacy and confidentiality are important to be less hesitant in discussing their concerns (Ball, et.al., 2015). Effective communication with adolescents requires seeing the patient alone, tailoring the discussion to the individual patient, and understanding the role of the parents with confidentiality (Ham, & Allen, 2012) NURS 6512 week 1 Building a Comprehensive Health History examples. According to Thompson (2010), obtaining a necessary ‘social history’ of each teenager can help to gain vital information about their relationships, assess the needs of the individual, and identify possible problems throughout the pregnancy. There are a number of issues relevant to teenage parents, such as; age, emotional maturity, relationship with parents/partner, educational needs, looked after children, social situation, and supporting young fathers-to-be (Thompson, 2010). The social history is a series of detailed questions creating the basis of the assessment and care plan. The care plan and assessment information is updated throughout the pregnancy and the plan is altered as the situation demands (Thompson, 2010).
Questions should be open-ended so that feedback is prompted, yet, declining to answer should be acceptable as well (Ball, et.al., 2015). For questions that are answered, further investigation can be encouraged to continue the evaluation of the situation. NURS 6512 week 1 Building a Comprehensive Health History examples. In addition, a screening tool or questionnaire at the pre-visit stage can also encourage a non-forced conversation by silently writing the concern rather than verbalizing the concern (Ball, et.al., 2015). Questions should pertain to thorough evaluation of her partner(s), sexually transmitted infection (STI) history, last menstrual cycle, medical history, previous gynecological visits, social/personal history (including current/previous smoking, drug or alcohol use), family history, and current outlook on the pregnancy. A time for the patient to ask any questions or express any concerns should be followed up, so that the patient is still involved and can feel in control and knowledgeable of the situation. A full head to toe assessment should be completed, including fetal heart tones. The patient-provider relationship should be respectful, useful, and effective with honest responses, making good eye contact, and maintaining non-judgmental respect of wishes.
Risk Assessment Instruments
As above, obtaining a social history can not only assess risky behaviors, discussing general social behaviors can also help to open the door to a better patient-provider relationship. The use of the screening tools HEEADSSS and PACES can guide adolescent issues such as sex, drugs, smoking, alcohol, peer pressure, home environment, and school (Ball, et al., 2015). The answers to these questions can help the provider obtain the knowledge and readiness of the patient’s needs for further educational needs and assistance from the provider (Ball, et al., 2015) NURS 6512 week 1 Building a Comprehensive Health History examples.
Health-Related Risk Potential
Other situations may arise that can be detrimental health concerns for the patient and the unborn child. Due to age, teenagers are at risk for not obtaining adequate prenatal care. This screens for medical problems in both mother and baby, monitors the baby’s growth, and deals quickly with any complications that arise. Prenatal vitamins with folic acid (ideally taken before getting pregnant) are essential to help prevent certain birth defects, such as neural tube defects (CDC, 2010). Pregnant teens have a higher risk of getting high blood pressure (pregnancy-induced hypertension) than pregnant women in their 20s or 30s (CDC, 2010). They also have a higher risk of preeclampsia, which is a dangerous medical condition that combines high blood pressure with excess protein in the urine, swelling of a mother’s hands and face, and organ damage (CDC, 2010) NURS 6512 week 1 Building a Comprehensive Health History examples. In addition, pregnant teens may be at higher risk of postpartum depression (CDC, 2010).
Several target questions may be used to help determine risks and build an up-to-date accurate health history. These questions may also help to obtain sexual history, any violence or potential violence, family support, and any other potential high risk endeavors that may harm the fetus or the patient. The questions below may be asked in a different sequence depending on the conversation and situation.
- When was your last menstrual cycle?
- Was this a planned pregnancy?
- Have you had any previous pregnancies?
- What is your current outlook on this pregnancy?
- How many sex partners have you had?
- Do you drink alcohol, smoke, or do recreational drugs? If so, how often?
- Do you have a good relationship with your parents?
- Have you ever been ‘in care’ or a ‘looked after child’?
- How does your parents feel about you being pregnant?
- Do you think your parents will support you?
- How are you doing in school?
- Do you have any questions for me?
Encouragement and education can go a long way with a teenager who is pregnant. A practitioner that can listen and treat to the best of their ability without judgement is one who has built a relationship on trust, honesty, and respect with the patient, no matter the age or circumstance. NURS 6512 week 1 Building a Comprehensive Health History examples. Thus, obtaining a health history that is accurate and reflects the patient’s situation, identifying the possible risk factors or complications that could arise.
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.
Center for Disease Control and Prevention (CDC). (2010). Reproductive Health: Teen Pregnancy. Retrieved from: http://www.cdc.gov/TeenPregnancy/index.htm.
Ham, P., & Allen, C. (2012). Adolescent health screening and counseling. American Family Physician, 86(12), 1109-1116.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Thompson, S. (2010). The complexities of supporting teenagers in pregnancy. British Journal Of Midwifery, 18(6), 368-372. NURS 6512 week 1 Building a Comprehensive Health History examples.