NURS 6512 week 1 Discussion: Building a Health History  

Developing or building an accurate and detailed patient history is a cornerstone of initiating an appropriate plan of care for any patient and is a skill that is essential for the APRN. In this way, we get to know our patient’s, their past concerns and issues, and how past problems impact current functioning. A complete health history is also necessary when collaborating with other healthcare clinicians or when there is a transfer of care. Factors such as age, gender, ethnicity, and living environment all should be considered since they greatly impact a patient’s health status. When interviewing a patient, whether it is a first encounter or follow-up care, communication, interviewing techniques, and other tools are necessary to ensure that the necessary information is gathered and understood to meet the needs of the patient. For the purpose of this discussion, the patient in question is a 14 year old biracial male living with his grandmother in a high-density public housing complex.

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Whenever meeting with any patient, I prefer to use a method called AIDET which is as follows: Acknowledge and greet the patient by name, make eye contact, smile, and include any others who are present; Introduce yourself, your position, and background or experience; the Duration that the interview and exams will take; Explain what steps are next and what the patient can expect from the visit; and lastly, Thank the patient and any family or friends for their time and consideration (Studer Group, 2020).. These steps can be completely in a few sentences, take less than five minutes, and can provide reassurance to nervous patients who don’t know what to expect.

While AIDET is an appropriate tool that can be used for most patient and situations, other communication and interview techniques may differ depending on the specific patient. For example, since this patient is an adolescent, I would first let him and his grandmother know that I will be speaking with them together and privately. While the grandmother may be necessary for background information, especially when the boy was younger, most adolescents are able to give an accurate health history and may speak more freely without the guardian if they are given the opportunity. However, adolescents may have difficulty choosing their words or may feel embarrassed so they should be given time to express themselves without confrontation, to which they do not respond well (Bell, Dains, Flynn, Solomon, & Stewart, 2019). In addition, there are specific topics that should be discussed with patients and their caregivers which are age-appropriate and referred to as anticipatory guidance (Sullivan, 2019). For example, topics to focus on for patients aged 10 to 14 years include safety issues, nutrition, dental hygiene, peer pressure, puberty, safe sex/contraception/STD prevention, safety rules with adults, communication, screen time, self-control, depression/anxiety, tobacco/alcohol/substance use, educational goals and activities, and after school activities, and supervision. NURS 6512 week 1 Discussion: Building a Health History

When interviewing any patient, social determinants of health should be considered and questions should be targeted towards identified areas of concern. Social determinants of health are socioecological factors such as gender, religion, ethnicity/race, sexual orientation, mental health, geographical location, education, income, employment, disabilities. Discrimination related to these factors cause disparities that negatively impact health and outcomes (Tebb, Pica, Twietmeyer, Diaz, & Brindis, 2018). Questions for this particular patient would be aimed towards factors such as his biracial status, being reared by a grandparent, and highly crowded public housing. Specific issues related to diseases in overcrowded environments such as tuberculosis should be assessed. I would also carefully monitor growth, milestones, and dietary habits since many individuals in urbanized areas live in food deserts without ready access to fresh, healthy, unprocessed foods.

When assessing a patient’s risk factors, especially once disparities in social determinants of health are identified, it is helpful to have a specific screening tool tailored to the demographic in question. For example, studies show that adolescents tend to have more social risks than medical ones. Therefore, tools such as The Guidelines for Adolescent Preventative Services (GAPS) was developed that targets primary and secondary interventions to prevent adolescent morbidity and mortality by improving health-care delivery (Sullivan, 2019). Risk taking behaviors in teens are identified, such as smoking, drinking, or unprotected sex, by 24 topics that examine health guidance, screening, immunizations, and health-care delivery. Another tool that was developed to assess drug and alcohol use in adolescents is the CRAFFT Questionnaire. CRAFFT refers to car, relax, alone, forget, friends, and trouble (Ball et al., 2019).

As mentioned above, adolescents tend to have more social risks than medical ones. Therefore, an assessment tool such as the HEEADSSS is helpful in obtaining an accurate psychosocial history for this age group. The acronym HEEADSSS stands for home, education/employment, eating, activities, drugs, sexuality, suicide/depression, and safety and encompasses many of the same social determinants (Sullivan, 2019).

Five specific questions targeted towards my patient to assess his health risks and build his health history are as follows: 1) Do you know anyone who has committed suicide? While suicide can be an uncomfortable subject, it is a common cause or mortality in teens, particularly in males, and should be assessed (Bell et al., 2019). This is a non-threatening question that may open the conversation and lets the teen know that this is a safe topic; 2) Are you sexually active? Adolescence is a time for experimenting and risk-taking behaviors. Children are becoming sexually active at younger ages and should be educated regarding safe sex, contraception, and disease prevention; 3) Do you safe at home? This question is a great open-ended question that can start the conversation and lead to a variety of safety-related issues. For example, does the boy feel safe with his grandmother? Answers to the contrary could indicate abuse or neglect. Maybe he does not feel safe in his living environment due to crowding in a public housing complex; 4) Tell me what you had for breakfast this morning? This question not only assesses the patient’s memory recall, but also may give an indication of nutrition and dietary habits; 5) Is there anything we have not talked about that you think I should know? Oftentimes the patient, especially ones who are young, may expect the clinician to guide the interview and answer questions that are posed. They may be more reluctant to initiate their own topics or concerns and this gives them to opportunity to have the floor to ask or discuss anything in a safe place.

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.

Studer Group. (2020). AIDET patient communication. Retrieved from https://www.studergroup.com/aidet#:~:text=The%20acronym%20AIDET%C2%AE%20stands,%2C%20Explanation%2C%20and%20Thank%20You.

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

Tebb, K.P., Pica, G., Twietmeyer, L., Diaz, A., & Brindis, C.D. (2018). Innovative approaches to address social determinants of health among adolescents and young adults. Health Equity, 2(1), 321-328. doi: 10.1089/heq.2018.0011.

Week 1: Building a Comprehensive Health History

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)

Required Media (click to expand/reduce)

Discussion: Building a Health History

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?

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. NURS 6512 week 1 Discussion: Building a Health History

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. NURS 6512 week 1 Discussion: Building a Health History
•  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. NURS 6512 week 1 Discussion: Building a Health History

Week 2 Case Studies