Building a Health History Example

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Building a Health History Example

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. Building a Health History Example

Effective communication is one of the most important techniques to get a more detailed patient history. As an advanced practice nurse, I should be aware of the factors need to consider in gathering the information to treat the patient. Such factors are age, gender, environment, and ethnicity. In my case, I have this 26-year-old female Lebanese who live in a graduate-student housing. Considering the patient’s age, gender, ethnicity, and the current environment are crucial during this health assessment.

 

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Establishing a meaningful partnership is an important element of high-quality care. Your patient is in a vulnerable situation while you as a provider is in a position of strength. This partnership is called patient-centered care as identified by the Institute of Medicine (IOM). Patient-centered care is defined as respecting and responding to the patient’s wants, needs and preferences, so they can make options in their care that suit their individual situation (IOM, 2001). The provider should be aware of the patient’s cultural beliefs and faith. Building a Health History Example

Effective communication technique is important in establishing a positive relationship with the patient such as courtesy, comfort, connection, and confirmation. Knocking at the door before entering a room is an example of courtesy, the same with addressing the patient in his/her preferred name, acknowledging others in the room, ensuring confidentiality, and paying attention to the patient while talking about the issue and not too much on taking notes and typing in electronic medical records, eye contact should be present. Providing comfort is important such as privacy by using curtains or shades, room temperature or offering a warm blanket. Maintaining good eye contact is crucial in connecting with the patient especially when it comes to cultural practices, consider what the patient has to say, try to avoid professional terms or jargon that the patient is difficult to understand, avoid being judgmental, respect patient’s silence, and define the concern clearly such as where is the concern, how severe, how long, and what aggravates the problem. With regards to confirmation, the provider should ask the patient to summarize the discussion to see if there is a clear understanding, open-ended questions can be implemented such as “Anything else you want to discuss?” As a provider, you have to acknowledge any mistakes and correct it, it is important to build a trusting relationship with the patient (Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019)

The risk assessment tool that I selected is obtaining a family health history. This information is helpful in determining risk both for common chronic conditions and more rare diseases as well. Although health risk assessment is time-consuming for the providers to do because of the allotted time per patient but getting all the information through this technique can greatly help identify the patient’s diagnosis (Wu, R.R., & Orlando, L. A., 2015).

Family health history is a record of the diseases and health conditions in your family. You and your family members share genes. You may also have behaviors in common, such as exercise habits and what you like to eat. You may live in the same area and come into contact with similar things in the environment. Family history includes all of these factors, any of which can affect your health (CDC, 2019). Building a Health History Example

 

The following are the questions that I would ask my patient who is a 26-year-old female Lebanese and currently living in a graduate-student housing. But I would introduce myself first, addressed the patient respectfully as he/she preferred, and provide privacy during the assessment.

  1. Why did you come today?
  2.  Do you prefer to be treated with a woman or man medical provider?
  3. Where is the discomfort or pain?
  4. How long is the discomfort?
  5. What aggravates it?
  6. How do your beliefs affect your health decision?
  7. When was your last menstrual period?
  8. What is your current living situation?
  9. Do you have family members who had a history of cancer, diabetes, hypertension, high cholesterol?

These are some of the questions that I would ask first for this specific patient. I know that each individual has their own religious and cultural beliefs. I learned that Lebanese prefers to be treated by the same-sex provider, cultural preferences might also affect the treatment of the patient.

 

 

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. Building a Health History Example

 

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.

 

CDC (2019). Family Health History: The Basics. Retrieved from https://www.cdc.gov/genomics/famhistory/famhist_basics.htm

 

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.

 

sample response

Building a detailed and accurate health history plays an instrumental role in the care planning process. However, Ball et al. (2019) the assessment of patients should be tailored to their specific situation because of the inherent variations in their age, gender, social determinants of health, and race/ethnicity. For example, I was assigned a 14-year-old, biracial male living with his grandmother in a high-density, public housing complex. Comparatively, you were assigned a 26-year-old Lebanese female living in graduate student housing. Thus, approaches for the two clients, including the assessment tools, are significantly different. You have highlighted the importance of effective communication establish a positive relationship with the client. I must add that cultural sensitivity is critical considering the ethnic minority status of the patient. Wu have Orlando (2015) have found that culturally competent assessment builds trust and prevents a judgmental attitude. On the other hand, you have identified the family health history as your preferred assessment tool for the patient. However, I propose partner violence screen (PVS) because of the gender and ethnicity of the client. Ball et al. (2019) have argued that ethnic minority women are often susceptible to violence and discrimination. The use of the tool will allow the nurse to assess the patient’s safety concerns and lived experiences as a minority woman. Building a Health History Example

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.). Elsevier Mosby

 

sample response 2

Thanks for your informative post. Your approach to building a health history is well put together. Some other ideas I would consider in this scenario are finances including health insurance and the ability to obtain food, proficiency in English and communication, and mental health coping mechanisms. Cultural differences including traditions, religious customs, and inhibitions, which may cause a cultural shock when trying to adapt to life on the university’s living situation. Mental health challenges such as anxiety, depression, and relationship problems are prevalent among university students, sometimes combined with recreational drug use, prescription drug abuse such as stimulants for studying, and alcohol consumption.

Privacy is of importance and offer the choice to the patient to her preference in the gender of the provider. Financial barriers are more common among women, persons of racial/ ethnic minorities, and sexual minorities who report perceptual barriers associated with stigma (Horwitz et al. 2020). Identity barriers based on age, gender, identity, and sexual orientation and efforts should be tailored to meet the unique needs of this specific Lebanese student’s needs. According to Ball (et al. 2019), females from ethnic minorities experience domestic or partner violence more often than other ethnic groups. Building a Health History Example

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.

 Horwitz, A. G., McGuire, T., Busby, D. R., Eisenberg, D., Zheng, K., Pistorello, J., Albucher, R., Coryell, W., & King, C. A. (2020). Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk. Journal of Affective Disorders, 271, 123–130. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jad.2020.03.115 Building a Health History Example