Discussion: Building a Health History

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NURS 6512 Week 1: Building a Comprehensive Health History

Discussion: Building a Health History

Discussion: Building a Health History

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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 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

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.

Post a 1 page paper APA format  1. a description of the interview and communication techniques you would use with your selected patient.

2. Explain why you would use these techniques.

3 Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient.

4 Provide at least five targeted questions you would ask the patient.

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

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)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

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).

 

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: 
  • 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

Next Module

To go to the next module:

Module 2

Initial Post: Obtaining a Health History

Obtaining a Health History

Obtaining a health history provides vital information regarding the patient’s current health status and previous diagnosis’ and treatment (Sullivan, 2019). This document is imperative to provide a foundation for the medical decisions and guidance to build from (Sullivan, 2019). As advanced practice registered nurses (APRNs) crucial to document a thorough health history, to best aid medical decision throughout the course of treatment and future visits. Failure to do so, or lack of important findings/information, may lead to insufficient care or misdiagnosis. Creating a safe environment for open communication can help the patient the feel relaxed and trusting, hopefully leading to good report with the provider.

Interview Description and Techniques Used

Patient Profile:

40-year-old black recent immigrant from Africa without insurance

Preceding the health interview, the patient’s vital signs, height and weight would be collected and reviewed by the APRN. Next the APRN should knock, wait for consent to enter. When given permission to enter, one must introduce his/herself while explaining the series of events that will occur, awaiting the patient’s permission. A quick assessment of language will help the provider know if he/she needs a certified interpreter. While conducting the interview, the provider should structure all questions as “Patient-Centered Questions”. Delivering the interview as patient-centered facilitates high quality care by incorporating the patient into the plan of care, allowing their wishes, needs, and cultural requirements to be considered and respected (Ball, 2019).

To improve patient responses to questions the APRN should be mindful of how the questions are phrased and be sure to ask one question at time, especially if the patient’s first language isn’t the same as the providers (Ball, 2019). Be sure to allow enough time between questions and respect pauses to avoid discouraging the patient from being complete in their response (Ball, 2019). When structuring a question, be sure to leave it open-ended. If more precise information is needed, provide a direct question, looking for specific information.

During the interview the APRN should be mindful of professionalism and body language. He/she should maintain eye contact, while reading body language of the patient to gage comfort level of the patient, and act accordingly, remain seated in front of the patient, not standing over them, provide privacy and ensure confidentiality, and maintain a professional dress code (Ball, 2019).

Explanation of techniques

Choosing to deliver the question in a patient-centered manner, will help establish good report through effective communication (Ball, 2019). Effective communication is built through courtesy, comfort, connection, and confirmation.

Courtesy

Showing common courtesy to a patient through asking permission, explain each step of a process, and common manners, can help a patient feel more secure. Being in a position as a provider, many patients feel this is a figure of authority and may feel vulnerable in your presents.

Comfort

When interviewing the patient, be sure you and patient are comfortable (Ball, 2019). Providing a comfortable environment can help decrease the amount of distraction that may hinder the patient from sharing their full story.

Connection

At the beginning of collecting the health history, always start with an open-ended question, such as: how have been? What brought you in today? Be mindful of the words you choose, avoiding demeaning phrases and medical terminology (Ball, 2019). The patient may not always share information with words. Be mindful of body language and ask questions appropriate to the observation.

Confirmation

At the end of the health history, be sure to summarize and clarify any areas that may been communicated unclearly. You should always leave an opportunity to share any further details about their medical, psychosocial, or financial situation that may be pertinent to the develop and guidance of the care plan. Asking “Is there anything else you’d like to add?” provides the patient the opportunity to share anything that may have been forgotten (Ball, 2019).

 

Risk Assessment Instrument

The risk assessment tool, I feel, is the most crucial for a new patient is SAD PERSONS scale. This scale was developed for medical students and non-psychiatric providers to help guide the possible risk of suicide in patients (Ng, How, &Ng, 2017). This is a mnemonic, where each positive answer is given one point (Ng et al., 2017). Scores of 3-4, the patient needs to be monitored. Scores of 5-6, strong consideration should be given to hospitalization. If the patient scores a 7 or greater, the patient must be admitted for further evaluation.

The acronym stands for:

Sex (male)

Age (<20 or >44)

Depression (history)

Previous suicide attempts

Ethanol abuse

Rational thinking loss (Psychosis)

Social support lacking

No spouse

Sickness (chronic or debilitating)

The worldwide rate of depression among migrates is approximately 15.6% (Foo et al., 2018). While this does not show a significant increase when compared to their native counterparts, the percentage does suggest a significant prevalence of depression throughout the migrant community. Those who have recently arrived and are unemployed, are more likely to experience depression (Foo et al., 2018)

This particular patient, recently moved their home country, where familiarity has been lost. Making a momentous decision, as to leave one’s home, may ignite feelings of regret and loneliness. Using the SAD PERSONS risk assessment will help the APRN properly evaluate the patient’s adjustment to the major life decision.

5 Targeted Questions

  1. Tell me what brought you in today.
  2. When did you move here?/how long have you been here?
  3. Do you have any support at home?
  4. Tell me how you are adjusting to your new environment
  5. Are you experiencing any feelings of anxiety, depression, sadness, nervousness, anger etc.?

Conclusion

Collecting a full and comprehensive health history give the medical team a foundation to work from. APRNs should interview each new patient to obtain a detailed time line of the patient’s medical, psychosocial, and family history. Maintaining effective communication and asking patient-centered questions should help nurture good report with the patient. Every new patient should be screened for depression and suicide ideation, but those of vulnerable populations should be evaluated with each visit, until normalcy is established.

 

Resources

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.

Foo, S., Tam, W., Ho, C., Tran, B., Nguyen, L., Mcintyre, R., &; Ho, R. (2018). Prevalence of Depression among Migrants: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health, 15(9), 1986. doi:10.3390/ijerph15091986

Ng, C., How, C., & Ng, Y. (2017). Depression in primary care: Assessing suicide risk. Singapore Medical Journal, 58(2), 72-77. doi:10.11622/smedj.2017006

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

NURS_6512_Week_1_Discussion_Rubric

Excellent Good Fair Poor
Main Posting
Points Range: 45 (45%) – 50 (50%)
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
Points Range: 40 (40%) – 44 (44%)
“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
Points Range: 35 (35%) – 39 (39%)
“Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.
Points Range: 0 (0%) – 34 (34%)
“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness
Points Range: 10 (10%) – 10 (10%)
Posts main post by Day 3.
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response
Points Range: 17 (17%) – 18 (18%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
Points Range: 15 (15%) – 16 (16%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.
Points Range: 13 (13%) – 14 (14%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
Points Range: 0 (0%) – 12 (12%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response
Points Range: 16 (16%) – 17 (17%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
Points Range: 14 (14%) – 15 (15%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.
Points Range: 12 (12%) – 13 (13%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
Points Range: 0 (0%) – 11 (11%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation
Points Range: 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on three different days.
Total Points: 100
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