NURS 6512 Building a Comprehensive Health History
NURS 6512 Building a Comprehensive Health History
Being able to obtain a comprehensive health history for a patient is important in developing a treatment plan for them. The purpose of this discussion post is to discuss interview techniques I would use for an 85-year-old white female living alone with declining health. I will talk about the risk assessment instrument I would use and why. Lastly, I will list five targeted questions I would ask to assess her health to start building a health history.
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The first meeting with any patient is so important to build a good relationship and partnership from the start (Ball et al., 2019). With this patient being 85 and living alone there will be a lot to consider when interviewing her. I will need to establish is she is mentally with it, if she has hearing problems, and how much she understands about her health. Older adults often assume certain problems are just normal parts of aging and not anything to be considered (Ball et al., 2019). Often, older adults can also experience agism (Garrison-Diehn et al., 2022). Even in health care settings older adults experience feelings of incompetence and being a burden (Garrison-Diehn et al., 2022). It will be important to make sure she feels comfortable speaking to me knowing there is no bias or judgement.
The risk assessment I would do for this patient is the functional assessment. This is an older lady who lives alone. It will be essential to figure out how well she is able to function on her own. One of the biggest risks for older patients is falling. Falling is associated with adverse outcomes that can lead to a patient not being able to live at home anymore along with increased mortality (Snehal et al., 2020). The functional assessment would give information regarding how well she can move around the house, is she is able to keep a clean environment, how meals are prepared, how she goes to the bathroom, and keeps good hygiene (Ball et al, 2019). All these issues are going to contribute to her overall health. It is important to gather this information to determine what assistance, if any, she will need.
After introducing myself and establishing how the patient would like to be addressed, I would start by simply asking “What brings you in today?” This is a way to find out what her chief complaint is for coming in. My second question would be “When did this start?” This brings the patient back to the beginning and prompts them to tell the whole story regarding why they came in. My third question would be “What medications do you take on a regular basis and what are they for?” In my experience patients may or may not even know what they are taking, let alone why they are taking them. It can also lead to her discussing if she is compliant with her medications. To follow that, my fourth question would be “What medical problems do you have?” Before going through a formal review of systems, this can give a clue to what she considers to be important in her history. My last question would be “How well do you feel you are able to take care of yourself at home?” This is an open-ended question to gain some insight on the functional assessment. If the patient’s initial chief complaint is not urgent it is okay to give the patient some time while understanding the time constraints of you as the provider (Ball et al., 2019).
Establishing a relationship with patients and getting a thorough health history can be a daunting task for providers. It is key to tailor interviewing skills to meet patient specific needs. Modifying interview skills to the individual will eliminate communication barriers between the provider and patient (Bass et al., 2019). Creating a strong relationship with the patient will allow the nurse practitioner to obtain the most comprehensive health history and provide the best possible care to clients.
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.
Garrison-Diehn, C., Rummel, C., Au, Y. H., & Scherer, K. (2022). Attitudes toward older adults and aging: A foundational geropsychology knowledge competency. Clinical Psychology: Science and Practice, 29(1), 4–15. https://doi.org/10.1037/cps0000043
Snehal, K., Rashmi, G., & Aarti, N. (2020). Risk factors for fear of falling in older adults in India. Journal of Public Health, 28(2), 123-129. doi:https://doi.org/10.1007/s10389-019-01061-9
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.
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
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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)
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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?
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• 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
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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
I really liked the way you presented your discussion post; it was very organized and thought out. However, as a PMHNP student, I was inclined to read through a few articles and I came across the following Risk assessment tools that would assess the psychological issues associated with one’s LGBTQIA status.
The Gender Minority Stress and Resilience Scale (GMRS) is used to measure the difficulties associated with identifying as a gender minority and protective factors for psychological well-being.The 58 items were adapted from other measures and compiled into the GMRS to measure nine different constructs, including Gender-related Discrimination, Gender-related Rejection, Gender-related Victimization, non-affirmation of Gender Identity, Internalized Transphobia, Negative Expectations for Future Events, and Nondisclosure (Shulman et al., 2017).
Strength of Transgender Identity Scale (STIS)This assesses how strongly an individual identifies as transgender and how important transitioning is to them. Although largely related to identifying transgender people, it contains items that may be relevant to understanding someone’s gender identity and how that might change in therapeutic interventions. The STIS has six questions and no factors were identified in the original validation study. Example items include “I identify as trans,” “It is important to me that people I am close to know I transitioned,” and “The fact that I transitioned is important to who I am.”
Transgender Adaptation and Integration Measure (TG AIM) measure the stresses associated with being transgender and the individual’s efforts to cope with stress. The TG AIM has 15 items, and three factors were identified in the initial validation study that is scored as subscales: Coping and Gender Reorientation Efforts, Psycho social Impact of Gender Status, and Gender-related Fears. A fourth factor, Gender Locus of Control, was also identified but was not recommended for use due to poor internal consistency. Example items of the three recommended factors include “I fear discrimination,” “I take/have taken hormones,” and “Being transgender causes me relationship problems.”
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.
Shulman, G. P., Holt, N. R., Hope, D. A., Mocarski, R., Eyer, J., & Woodruff, N. (2017). A review of contemporary assessment tools for use with transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 4(3), 304–313. https://doi.org/10.1037/sgd0000233Links to an external site.
Effective nursing health assessment interview techniques. (n.d.). Walden University. https://www.waldenu.edu/online-bachelors-programs/bachelor-of-science-in-nursing/resource/effective-nursing-health-assessment-interview-techniquesLinks to an external site.