The Comprehensive History and Physical Exam Assignment

NURS 6512N WEEK ONE DISCUSSION INSTRUCTIONS

TOPIC: 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. The Comprehensive History and Physical Exam Assignment

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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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.

Here is your assigned patient for Week 1. You will only have one to address in the discussion board.

1. 4 year old African American male living in a rural community

To prepare:

With the information presented in Chapter 2 of Ball et al. 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 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? The Comprehensive History and Physical Exam Assignment
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select oneof the risk assessment instruments presented in Chapter 2 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 fivetargeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

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.

REQUIRED READING:

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach(10th ed.). St. Louis, MO: Elsevier Mosby.
  • Chapter 2, “The History and Interviewing Proce
    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” The Comprehensive History and Physical Exam Assignment
    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)
• Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unitLinks to an external site.. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0
• Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the EDLinks to an external site.. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015
• Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced levelLinks to an external site.. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238

Shadow Health Support and Orientation Resources The Comprehensive History and Physical Exam Assignment

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

• Shadow Health. (2021). Welcome to your introduction to Shadow HealthLinks to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.). Shadow Health help deskLinks to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.Download Walden University quick start guide: NURS 6512 NP students.
• Document: Shadow Health Nursing Documentation TutorialDownload Shadow Health Nursing Documentation Tutorial(Word document)

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. The Comprehensive History and Physical Exam Assignment