BUILDING A HEALTH HISTORY NURS 6512
BUILDING A HEALTH HISTORY NURS 6512
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.
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.
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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
I enjoyed reading your post about communication with an 85 year old patient. It is important to build a report with the patient so they feel comfortable speaking with you. When evaluating the patient to find out if they are mentally intact it is important to not lead them to answers. Even though the patient has a decline in her health she may be mentally still intact. Open ended questions are important because it allows the patient to express themselves. This may help you find out if they are understanding the question or are they trying to hide any deficits. Using closed ended questions can also help you identify how their memory is. Providing questions with random words to remember will help you assess this piece of brain functionality when it comes to remembering things. It is important to know where the patient is at with memory and cognitively because this can raise some red flags when it comes to safety in their home. When I worked in home care as a care coordinator I had done many evaluations of elderly people in my community to see if they are safe to be at home or are they needing a different level of care. I was able to help family members realize safety concerns for the patient by being able to do these assessments.
One question that ended up coming up a lot was will the patient remember they are cooking something or are they at risk of starting a fire. During one of my evaluations I ended up finding that the patient was not safe to cook in the home. I ended up having to unplug the stove and the other cooking devices with the help of the family members until they were able to get the patient placed with a higher level of care.
It would also be important to do a fall assessment on this patient to see if there are risks for falls and if the patient did have a fall would their be away they could alert someone if they got injured. Walking around and doing a survey of the home was part of these assessments. I also observed the patient while they went about doing their normal routine without correcting them because I would want to see what they would do if I was not there. If it became too much of a risk than I would stop and make note of findings while making sure the patient is safe.
When asking the patient questions, I will not dominate the conversation. I will actively listen by providing non-verbal cues to the patient that shows that I am listening to the patient when they are speaking while not leading the patient to answers during the evaluation of their safety in their home.
Ball, J., 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.
Mayo Foundation for Medical Education and Research. (n.d.). Physical Medicine and Rehabilitation. Mayo Clinic. Retrieved June 4, 2022, from
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Week 1 Nurs-6512N-47 Advanced Health Assessment
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Week 1- Nurs-6512N-47 Advanced Health assessment
85-year-old white female living alone with no family in declining health
My assignment is based on working with an 85-year-old white female living alone with no family in declining health. While working on this task, I assume the patient is my mother, and I interrogate him with empathy, knowing that she is an elderly person who is likely to be more isolated and lonelier than individuals living with their loved ones. Here, I need to create an interviewing strategy to employ in assessing this patient’s medical condition, taking into account his advanced age that his health is declining.
Communication is a difficult endeavor that requires empathy and courtesy, especially when dealing with senior individuals. It’s critical to observe, listen, and gather information when pertinent information is offered when speaking with these kinds of patients. To preserve a constant pace with the patient, the medical practitioner not only should go slowly and be very patient (Ball et al., 2019). Furthermore, by observing, the healthcare professional can connect to and be brought into the environment of the elderly. It is critical to comprehend the participant’s reality and the circumstances that may impact their responses. It’s critical for health care professionals to establish a good connection with patients in the interview session to create a favorable interaction.
The nurse tells the patient to introduce themselves to create familiarity and as the patient settles in the interview. Showing sincerity is vital while getting to know the social circle’s nature and the living condition of the patient. The questions could be personal, but they are meant to know the situation of the healthcare provider.
Target Health Question
The impact of social determinants on patient health is an important issue to consider when assessing a patient’s health. Food availability, social support, social position, and low-income levels, are all closely linked to premature death and higher incidents of sickness, based on empirical evidence. Inquiring into social determinants of health and how they affect the patient’s health can be a touchy subject (Ryan, 2019). As a result, I’d organize my queries in a way that respects the older patient while also demonstrating empathy and sincerity for their plight. Moreover, because such individuals may have difficulties communicating their conditions and ideas, I would be using effective listening skills.
The arranging of the patient’s health record through the Subjective Objective Assessment (SOAP) and Plan Problem Oriented Medical Record (POMR) would be appropriate tools for the assessment of this patient. The POMR tool is an effective instrument as it provides for a thorough recording and assessment of medical information about a patient (Pdhi.com, 2022). Furthermore, it enables the collection of data from all care team members in order to ascertain the diagnosis and develop an empirical medication regimen. POMRs often include the patient’s condition, complaints, test findings, and a care plan that enables the medical practitioner to address each issue individually, write patient records, and a review of discharge with instructions for follow-up (Feldman et al., 2021).
Since the patient is elderly and has a declining health status, there are certain risks that are mainly linked to social health determinants. Old age put the patient at risk of falling (Abdi et al., 2019). As such, the health care provider should investigate if she has already incurred any injuries from falling.
Five Target Questions
On the first encounter, it is vital to first build a connection and therapeutic relationship with the patient to make them comfortable to open up. This way, there would be mutual understanding, which is essential in knowing the needs of the patients. Some of the questions, I would ask include;
- Do you experience any pains?
- What do you think could be the reasons for your symptoms?
- Are you under any medication?
- What do you think of your quality of life?
- Have any medications triggered any allergies in you?
Abdi, S., Spann, A., Borilovic, J., de Witte, L., & Hawley, M. (2019). Understanding the care and support needs of older people: a scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatrics, 19(1). https://doi.org/10.1186/s12877-019-1189-9
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
Feldman, R., Chiu, M., Lawson, A., & Sadavoy, J. (2021). Evaluating Caregiver Risk: The Dementia Caregiver Interview Guide. Psych, 3(4), 552-561. https://doi.org/10.3390/psych3040036
Pdhi.com. (2022). What is a Health Risk Assessment? | ConXus Platform. Pdhi.com. Retrieved 2 June 2022, from https://www.pdhi.com/ncqa/what-is-a-health-risk-assessment/.
Ryan, L. (2019). Clinical Applications of a Smart Physical Examination System for the Health Management in Elderly. Case Medical Research. https://doi.org/10.31525/ct1-nct03858660