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.
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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.
Sample Answers
1.
Health assessment
Week one
Initial discussion
Building the patient history
Introduction stage
I would enter the room and introduce myself to the patient. After making a quick visual assessment, I would ask what brings her here. I would allow the patient to express any concerns or I would explain to the young adult that I will be asking a series of question about her and her family’s medical history. Then, if they patient is ready, I will begin building my history. I would do a thorough head to toe assessment with vitals and document her baseline findings to have in her medical record.
Communication techniques
To effectively communicate with your patient, a practitioner must know and understand their culture and beliefs and religion. The world is very diverse. Patient will open up or shut down if the practitioners first impression is negative. The practitioner must be culturally competent and understanding the different choices a patient may have on life death and medical treatment. The practitioner must observe the environment of the room, especially the patient to make sure that we are not offending the patient. Communication should be concise and clear. The practitioner should actively listen to the patient so that the patient feels valued and comfortable with the provider. The patient should be included in the whole intake process. The practitioner should encourage the patient to ask questions and re-state information thought during the session to validate their learning and understanding (Ball, Dains, 2019).
Risk assessment tools used
My patient is an early adult living in a dorm doing graduate studies. She is also Lebanese. I would use the patient strength questionnaire to assess the young lady stress level. I would focus on her accomplishments and satisfaction at this point in her life (Armstrong, 2019). I would explore any insecurities with open ended questions where she can elaborate on a topic if she wants to.
Five potential questions
Do you have any aches, pains or health concerns you want to address today?
When was your last menstrual cycle? Was it normal?
Have you had your meningitis shot? I would also ask about symptoms of meningitis here.
What do you do to relieve stress and anxiety?
Is there a history of cancer or chronic illnesses in your family?
References
Armstrong, A. (2019) 12 Stages of Life Retrieved from: https://www.institute4learning.com/resources/articles/the-12-stages-of-life/
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
2.
Week 1 Discussion
COLLAPSE
Building a Health History
Taking a patient’s health history is a key component to build the patient’s health profile. Using effective communication techniques is essential to developing accurate and comprehensive patient medical history. Also, a thorough health assessment promotes health maintenance and disease prevention (Wu & Orlando, 2015). To develop successful patient-centered care and nurse-patient relationship, the nurse practitioner’s (NP) main objective is to find out the details on the patient chief complaints and the expectation of the visit (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Also, NP should show sincere interest by asking the patient what is the main concern and NP should maximize the ability to help (Ball et al., 2019).
Communication Techniques
Since each patient is different, using different communication techniques is necessary to perform a thorough patient assessment that is based on the patient ethnic background, socio-economic, education, gender, and knowledge about the disease. Asking direct, open-ended questions, and a question that leads the patient to focus on specific thoughts during body system assessment to enhance patient response (Ball et al., 2019). When asking personal, sensitive questions, tell the patient the reason why the question is being asked. One example is when asking the patient question about physical violence is required by law to help the patient get the care they needed and for safety. Throughout the assessment, the NP should maintain good eye contact if appropriate (Ball et al., 2019).
Non-verbal communication has a strong impact during patient encounters as it demonstrates the nurse’s interest to connect with the patient, respect, and empathy (Vogel, Meyer, & Harendza, 2018). Also, confirmation is knowledge testing of the patient by asking the patient an open-ended question to assess understanding of the discussion and clarify misunderstanding at the end of the visit (Ball et al., 2019). Using different effective communication will enhance the nurse-patient partnership.
Building Health History
The target question for building the patient’s health history includes the patient’s social determinants, medical history, and family history. According to Lushniak, 2015, taking family history is the most available, simple, and affordable “genomic tool” to assess the patient’s risk factors, disease prevention, diagnosis, and treatment (p. 3, para. 1). The social determinants that the NP should assess are the patient’s age, social history includes the intake of alcohol and tobacco (Sullivan, 2019). Also, assess cultural and religious practices because they can affect health promotion, maintenance, and treatment (Sullivan 2019). Other social determinants that should be assessed include gender, childhood development, employment, income, housing, and social support (Andermann, 2016, para. 4).
Scenario
A 26-year-old Lebanese female living in graduate-student housing.
Assessment
The assessment starts with identifying the patient’s date of birth, age, gender identity, race, and referral source (Ball et al., 2019, p. 6). The assessment will begin with asking the patient her chief concern, the history of the present problem, past medical history including surgery, family history, social history, and a review of body systems (Ball et al., 2019, p. 6). Social history should include alcohol, tobacco, and drug use. Also, the cultural assessment includes dietary preferences, beliefs, and practices, and faith-based rituals, (Ball et al., 2019, p. 26). Assessment will also include drug allergy, current, and past medication use, vaccination, and health directive (Ball et al., 2019, p. 11). Other questions will include if she is married, children, number of pregnancies, number of competed pregnancies, abortion, and if she is sexually active.
One health risk assessment tool that will be used to the patient is FICA because of her ethnic background (Ball et al., 2019, p. 10). The other risk assessment tool is SBIRT to screen for drug and alcohol if applicable, the five Ps to assess the patient’s sexual history and HITS for domestic violence if applicable (Ball et al., 2019, p. 27, 31). Furthermore, RESPECT model to bridge cultural differences between patients and health providers (Ball et al., 2019, p. 30).
Targeted Questions
Please tell me the reason for your visit?
Explain how the problem started and how long you have been experiencing the problem?
Please tell me what steps have you done to treat the symptoms and have you sought medical help before today?
Are there any recent events in your life that could have to cause the problem?
What is your expectation for today’s visit that will help your problem?
Has the problem affected your life, if yes, please explain how?
References
Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: A framework for health professionals. Canadian Medical Association, 188(17-18), E474–E483. doi:10.1503/cmaj.160177. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135524/
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.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis Company.
Vogel, D., Meyer, M., & Harendza, S. (2018). Verbal and non-verbal communication skills including empathy during history taking of undergraduate medical students. BMC Medical Education, 18(1), 157. doi:10.1186/s12909-018-1260-9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6029273/
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, 91(1079), 508. doi:1 0.1136/postgradmedj-2014-133195. Retrieved from: https://search-proquest-com.ezp.waldenulibrary.org/docview/1781654997?accountid=14872
3.
COLLAPSE
Building a Health History
Building a relationship of patient-provider trust can be achieved through caring about differences and adapting care based upon the patient’s culture and background and is key to meeting the individuals needs of each patient (Ball et al., 2019). This week discussion would be focused on building a health history for LN, a 14-year-old biracial male living with his grandmother in a high-density public housing complex.
Summary of the interview
Case # 2
14-year-old biracial male living with his grandmother in a high-density public housing complex.
Subjective: LN is a 14-year-old male high school student. He practices baseball activities twice a week at school. He denies any medical issue and takes over-the-counter calcium supplements medications once a day because he is allergic to lactose and try to avoid dairy product as much as possible. He does not take breakfast in the morning and only eat a small portion of food at school during lunch. He stated that he does not like school food and prefers dinner. He stated that he avoids eating carbohydrate food because he does not want to be fat. He does not smoke, drinks alcohol, or use drugs.
Objective: General appearance: A tall and slim youth boy, healthy appearance, the abdomen is flat, the height of 5’8, weight of 130 and a BMI of 19.2 (borderline on the lower side of normal weight). Well-kept hair, teeth, skin, and nails overall. LN’s vital signs are stable.
Communication technique
In a process of completing an accurate health assessment, it is imperative to conduct a comprehensive historical health assessment starting with what the patient has to say about himself before moving to what is going on with the patient. This approach enables the nurse practitioner to consider holistic factors that impact the patient’s health. Ball et al., (2019) stated that you will be amazed by how many times a complete history is provided without prompting, later as information accumulates, you will need to be more specific. However, early on, it is entirely appropriate to check the patient’s agenda and concerns and let the information flow (Ball et al., 2019). Communication is an important and necessary ongoing process during a health assessment interview. A nurse practitioner should be able to have an overview of all the stressors affecting the patient’s health and wellbeing and be able to link those stressors together. Having clear and agreed-upon goals for each interaction leads to successful communication. You must be a skilled listener and observer with a polished sense of timing and a kind of repose that is at once alert and reassuring (Ball et al., 2019).
Risk assessment
The American Medical Association Department of Adolescence Health developed the Guidelines for Adolescent Preventive Services (GAPS) with the goal of improving health care delivery to adolescents using primary and secondary interventions to prevent and reduce adolescent morbidity and mortality (Sullivan, 2019). GAPS consist of 24 topics that encompass Health Care delivery, health guidance, screening, and immunizations. The screening tool HEEADSSS, which stands for home, education, employment, eating, activities, drugs, sexuality, suicide, depression, and safety (Sullivan, 2019), is indicated for LN risk assessment as it includes the eating habit screening. The choice was made based on LN subjective health assessment data.
Targeted questions
1- What do you think will be a healthy diet?
2- How does that compare to your current eating patterns?
3- Have there been any recent changes in your weight?
4- Have you ever made yourself throw up on purpose to control your weight?
5- Have you ever tried lactose-free milk or other milk products?
Conclusion
Adolescent living in a high-density public housing complex is at high risk for tobacco, alcohol, and other drug abuse. Using HEEADSSS screening for adolescents helps detect potential risk factors. Jarvis (2016), stated that “diagnostic reasoning is the process of analyzing health data and drawing conclusions to identify diagnosis” (Jarvis, 2016, p.8). LN is at risk for imbalanced nutrition related to lactose intolerance as evidenced by avoiding breakfast in the morning due to the presence of dairy products in many breakfast products. He is also at risk for Knowledge deficiency related to lack of dairy food consumption, lack of information about lactose-free dairy food and increased risk of malnutrition, as evidenced by skipping breakfast every day and BMI borderline on the lower side of normal weight.
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.
Jarvis, C. (2016). Physical Examination and Health Assessment, Seventh Edition. St. Louis,
Missouri: Elselvier.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis
