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NURS 6512N 32 Week 1 Discussion: Building a Health History

NURS 6512N 32 Week 1 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: 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.
  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

Module 2: Functional Assessments and

Assessment Tools

Accessible player
What's Happening in This Module?
Module 2: Functional Assessments and Assessment Tools is a 2-week module, Weeks
2 and 3. In this module, you consider the impact of functional assessments, diversity,
and sensitivity in conducting health assessments. You also explore various assessment
tools and diagnostic tests that are used to gather information about patients’ conditions
and examine the validity and reliability of these tests and tools. Finally, you examine
assessment techniques, health risks and concerns, and recommendations for care
related to patient growth, weight, and nutrition.
What do I have to do?     When do I have to do it?
Review your Learning Resources. Days 1–7, Weeks 2 and 3

Discussion: Diversity and Health
Assessments

Post by Day 3 of Week 2, and respond to your
colleagues by Day 6 of Week 2.

Case Study Assignment: Assessment
Tools and Diagnostic Tests in Adults
and Children

Submit your Case Study Assignment by Day 6
of Week 3.

DCE: Health History Assessment

You are encouraged to work on your DCE
every week. However, this Assessment is not
due until Day 7 of Week 4.

Go to the Module's Content

NURS 6512N 32 Week 1 Discussion Building a Health History

NURS 6512N 32 Week 1 Discussion Building a Health History

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Week 2: Functional Assessments and
Cultural and Diversity Awareness in Health

Assessment

Diversity is not about how we differ. Diversity is about embracing one another's

uniqueness.
—Ola Joseph

Countless assessments can be conducted on patients, but they may not be useful. In
order to ensure that health assessments result in the necessary care, health
assessments should take into account the impact of factors such as cultures and
developmental circumstances.
Learning Objectives
Students will:
 Analyze diversity considerations in health assessments
 Apply concepts, theories, and principles related to examination techniques, functional
assessments, and cultural and diversity awareness in health assessment
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”  (Previously read in
Week 1)
This chapter highlights history and interviewing processes. The authors
explore a variety of communication techniques, professionalism, and
functional assessment concepts when developing relationships with
patients.

 Chapter 2, “Cultural Competency”
This chapter highlights the importance of cultural awareness when
conducting health assessments. The authors explore the impact of culture
on health beliefs and practices.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 Chapter 2, “Evidenced-Based Clinical Practice Guidelines”
Melton, C., Graff, C., Holmes, G., Brown, L., & Bailey, J. (2014). Health
literacy and asthma management among African-American adults: An
interpretative phenomenological analysis. Journal of Asthma, 51(7),
703–713. doi:10.3109/02770903.2014.906605
Credit Line: Health literacy and asthma management among African-American adults: An interpretative phenomenological
analysis by Melton, C., Graff, C., Holmes, G., Brown, L., & Bailey, J., in Journal of Asthma, Vol. 51/Issue 7. Copyright 2014 by
Taylor & Francis, Inc. Reprinted by permission of Taylor & Francis, Inc. via the Copyright Clearance Center.

The authors of this study discuss the relationship between health literacy
and health outcomes in African American patients with asthma.
Centers for Disease Control and Prevention. (2015). Cultural competence.
Retrieved from https://npin.cdc.gov/pages/cultural-competence

This website discusses cultural competence as defined by the Centers for
Disease Control and Prevention (CDC). Understanding the difference
between cultural competence, awareness, and sensitivity can be obtained
on this website.
United States Department of Human & Health Services. Office of Minority
Health. (n.d.). A physician's practical guide to culturally competent care.
Retrieved June 10, 2019, from https://cccm.thinkculturalhealth.hhs.gov/

From the Office of Minority Health, this website offers CME and CEU
credit and equips healthcare professionals with awareness, knowledge,
and skills to better treat the increasingly diverse U.S. population they
serve.

Espey , D. K., Jim, M. A., Cobb, N., Bartholomew, M., Becker, T.,
Haverkamp, D., & Plescia, M. (2014). Leading causes of death and all-
cause mortality in American Indians and Alaska Natives. American Journal
of Public Health, 104(Suppl 3), S303–S311.

The authors of this article present patterns and trends in all-
cause mortality and leading cause of death in American
Indians and Alaskan Natives.

Wannasirikul, P., Termsirikulchai, L., Sujirarat, D., Benjakul, S., &
Tanasugarn, C. (2016). Health literacy, medication adherence, and blood
pressure level among hypertension older adults treated at primary health
care centers. Southeast Asian Journal of Tropical Medicine and Public
Health, 47(1), 109–120.

The authors of this study explore the causal relationships
between health literacy, individual characteristics, literacy,
culture and society, cognitive ability, medication adherence,
and the blood pressure levels of hypertensive older adults
receiving healthcare services at primary healthcare centers.

Required Media (click to expand/reduce)

Module 2 Introduction

Dr. Tara Harris reviews the overall expectations for Module 2. Consider
how you will manage your time as you review your media and Learning
Resources for your Discussion, Case Study Lab Assignment, and your

DCE Assignment (3m).

Accessible player

Name:  Discussion Rubric

  Excellent

90–100

Good

80–89

Fair

70–79

Poor

0–69

Main Posting:

Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

40 (40%) – 44 (44%)

Thoroughly responds to the Discussion question(s).

Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

No less than 75% of post has exceptional depth and breadth.

Supported by at least three current credible sources.

35 (35%) – 39 (39%)

Responds to most of the Discussion question(s).

Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.

50% of the post has exceptional depth and breadth.

Supported by at least three credible references.

31 (31%) – 34 (34%)

Responds to some of the Discussion question(s).

One to 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.

Cited with fewer than two credible references.

0 (0%) – 30 (30%)

Does not respond to the Discussion question(s).

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 references.

Main Posting:

Writing

6 (6%) – 6 (6%)

Written clearly and concisely.

Contains no grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

5 (5%) – 5 (5%)

Written concisely.

May contain one to two grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

4 (4%) – 4 (4%)

Written somewhat concisely.

May contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

0 (0%) – 3 (3%)

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 Posting:

Timely and full participation

9 (9%) – 10 (10%)

Meets requirements for timely, full, and active participation.

Posts main Discussion by due date.

8 (8%) – 8 (8%)

Meets requirements for full participation.

Posts main Discussion by due date.

7 (7%) – 7 (7%)

Posts main Discussion by due date.

0 (0%) – 6 (6%)

Does not meet requirements for full participation.

Does not post main Discussion by due date.

First Response:

Post to colleague’s main post that is reflective and justified with credible sources.

9 (9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

8 (8%) – 8 (8%)

Response has some depth and may exhibit critical thinking or application to practice setting.

7 (7%) – 7 (7%)

Response is on topic and may have some depth.

0 (0%) – 6 (6%)

Response may not be on topic and lacks depth.

First Response:

Writing

6 (6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully 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.

5 (5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in standard, edited English.

4 (4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

0 (0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.

First Response:

Timely and full participation

5 (5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

4 (4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

3 (3%) – 3 (3%)

Posts by due date.

0 (0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.

Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)

Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

8 (8%) – 8 (8%)

Response has some depth and may exhibit critical thinking or application to practice setting.

7 (7%) – 7 (7%)

Response is on topic and may have some depth.

0 (0%) – 6 (6%)

Response may not be on topic and lacks depth.

Second Response:
Writing
6 (6%) – 6 (6%)

Communication is professional and respectful to colleagues.

Response to faculty questions are fully 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.

5 (5%) – 5 (5%)

Communication is mostly professional and respectful to colleagues.

Response to faculty questions are mostly answered, if posed.

Provides opinions and ideas that are supported by few credible sources.

Response is written in standard, edited English.

4 (4%) – 4 (4%)

Response posed in the Discussion may lack effective professional communication.

Response to faculty questions are somewhat answered, if posed.

Few or no credible sources are cited.

0 (0%) – 3 (3%)

Responses posted in the Discussion lack effective communication.

Response to faculty questions are missing.

No credible sources are cited.

Second Response:
Timely and full participation
5 (5%) – 5 (5%)

Meets requirements for timely, full, and active participation.

Posts by due date.

4 (4%) – 4 (4%)

Meets requirements for full participation.

Posts by due date.

3 (3%) – 3 (3%)

Posts by due date.

0 (0%) – 2 (2%)

Does not meet requirements for full participation.

Does not post by due date.

Total Points: 100

Name:  Discussion Rubric

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