NURS 6512 Week 1: Building a Comprehensive Health History 

Sample Answer for NURS 6512 Week 1: Building a Comprehensive Health History Included After Question

NURS 6512 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 health care 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 factors such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how these factors 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 age, gender, ethnicity, or environmental setting 
  • Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information 

Photo Credit: Hero Images/Hero Images/Getty Images 

NURS 6512 Week 1: Building a Comprehensive Health History 
NURS 6512 Week 1: Building a Comprehensive Health History

Learning Resources  

Required Readings 

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

  • Chapter 1, “The History and Interviewing Process” (pp. 1–21)  

 

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 26, “Recording Information” (pp. 616–631)  

 

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 1, “Medicolegal Principles of Documentation” (pp. 1–14 and abbreviations, pp. 19) 

 

  • Chapter 2, “The Comprehensive History and Physical Exam” (pp. 23-32) 

Note about Uploading Media: 

Please refer to the Kaltura Media Uploader page located in the course navigation menu.. The documents on this page provide guidance on how to upload media for your Health Assessment Videos assignments for this course. 

 

Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnen, V., L Van Abbema, D. & Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: results of a cohort study. BMC Family Practice, 16(30), 1–12. doi 10.1186/s12875-015-0241-x. Retrieved from http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0241-x 

 

 

Wu, R. R. & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: barriers and benefits. Post Grad Medical Journal, 91 (1079), 508–513. doi:10.1136/postgradmedj-2014-133195. Retrieved from http://pmj.bmj.com/content/91/1079/508 

 

 

Lushniak, B. D. (2015). Surgeon General’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, 130(1), 3–5. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245280/ 

 

 

Jardim. T. V., Sousa, A., Povoa, T., Barroso, W., Chinem, B., Jardim, L., Bernardes, R., Coca, A., & Jardim, P. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Family Practice, 15(1111), 1–7. doi 10.1186/s12889-015-2477-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642770/ 

 

Optional Resources 

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical. 

  • Chapter 2, “History Taking and the Medical Record” (pp. 15–33) 

 

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 one of the following new patients: 

  • 76-year-old Black/African-American male with disabilities living in an urban setting 
  • Adolescent Hispanic/Latino boy living in a middle-class suburb 
  • 55-year-old Asian female living in a high-density poverty housing complex 
  • Pre-school aged white female living in a rural community 
  • 16-year-old white pregnant teenager living in an inner-city neighborhood 

To prepare: 

With the information presented in Chapter 1 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 age, gender, ethnicity, or environment? 
  • What risk assessment instruments would be appropriate to use with each patient? 
  • What questions would you ask each patient to assess his or her health risks? 
  • Select one patient from the list above on which to focus for this Discussion. 
  • 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 26 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 

Post a description of the interview and communication techniques you would use with your selected 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 

Respond to at least two of your colleagues on two 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 and Respond by Day 6 

 

To participate in this Discussion: 

Week 1 Discussion 

 

 

Looking Ahead: Physical Health Assessment Videos 

This course requires that you demonstrate proficiency in conducting physical health assessments, including a health history and a head-to-toe physical examination. You will demonstrate this proficiency by videotaping yourself as you perform the assessments. You will need to have access to a video recorder to capture the required physical health assessments on video. Additionally, you will need to obtain the necessary equipment required to perform these physical health assessments, including a stethoscope, an otoscope, an ophthalmoscope, a pocket eye chart, a tape measure, a reflex hammer and tuning forks (Frequency of 500-1000Hz to be used).  All of the required equipment must be used in order to pass the video and you must pass each video with a score >69.5% in order to pass the course.  You will also need to have a volunteer to act as your “patient” for each physical assessment. Your volunteer patient must be over 18 years of age, non-pregnant, and willing to be available for the entire video session. Each volunteer must sign the Video Release Form located on the Kaltura Media Uploader page located in the course navigation menu. The signed form must be faxed to the following toll-free number prior to recording each Video Assignment: 888–546–7564. Note: You may use the same volunteer for each video if appropriate.  

Throughout this course, you will create and submit three physical health assessment videos.  

Week 3: Health History  

In Week 3, you will videotape yourself collecting a “patient’s” health history. This video is due by Day 7 of Week 4. 

Week 8: Skin, Hair, and Nails and HEENT Assessment  

By Day 7 of Week 8, you will create and submit a video of yourself conducting a Skin, Hair, and Nails and HEENT assessment 

Week 10: Head-To-Toe Physical Assessment  

By Day 7 of Week 10, you will create and submit a video of yourself conducting a head-to-toe physical exam. 

Submitting Your Videos  

All videos will be submitted through the weekly assignment submission area using the Kaltura Media option available via the mashup tool. Refer to the Kaltura Media Uploader page in the course navigation menu for more information about uploading media for assignments. 

Note: Although you will only film and submit the health history, partial physical exam, and head-to-toe physical exam video assessments in Weeks 4, 8, and 10, respectively, it is highly recommended that you view each week’s media and practice performing the related health assessment on family members and/or patients. For example, in Week 7, you study the abdomen and gastrointestinal system. After watching the media assigned in that week’s Learning Resources, it is recommended that you practice conducting an abdominal examination.  

To submit your completed Video Assignment(s), do the following:If you have not already done so, click on the Week 8 Assignment link. Once you have clicked on the link, click on the Write Submission button to turn on the Content Editor toolbar. Next, fill in the Submission field with any pertinent information. Attach your Assignment file by clicking on the Mashup button on the text editor menu bar and select Kaltura Media. Then find the media file you saved as “WK6Assgn+first initial+last name” and click on Open. Add any appropriate comments pertaining to your Assignment(s) in the Comments field. Be sure to attach all your video assignments. Finally, click on the Submit button to turn in your Assignment(s) for review. 

For additional details on using the Kaltura Media mashup tool, please refer to the Kaltura Media Uploader page located in the course navigation menu. 

A Sample Answer For the Assignment: NURS 6512 Week 1: Building a Comprehensive Health History 

Title: NURS 6512 Week 1: Building a Comprehensive Health History 

Week in Review 

This week, you identified various communication techniques used to obtain important patient health histories. In addition, you applied patient interviewing concepts, theories, and principles to retrieving and recording patient information. 

Next week, you will explore various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.  

Interview and Communication Techniques 

            During the interview of a 16-year-old white pregnant teenager living in an inner-city neighborhood, the techniques to build a health history should be thoughtfully and compassionately carried out.  Firstly, it is recommended during any interview that it take place in a comfortable setting.  It is advisable to stray away from equipment or desks/tables unintentionally creating a barrier between the provider and the patient.  The provider should sit eye level with the patient, relaxed, with a calm tone of voice.  These techniques will help the provider establish a relationship with the patient; gaining the patient’s trust, thus obtaining an accurate and thorough health history (Ball, Dains, Flynn, Solomon, & Stewart, 2015). 

Secondly, the patient is an adolescent still.  When the provider introduces him/herself to the patient, anyone accompanying the patient should also be identified and addressed by name.  If there is a parent with the patient, the provider should learn the parent’s name and involve the parent.  However, a patient over the age of seven can typically be a dependable reporter for health information and the patient should be allowed confidentiality and privacy.  Adolescents may be reluctant to disclose certain information in front of a parent and wish to speak with the provider privately.  It is important to honor these wishes yet involve the parent and the patient’s support system in the patient’s care.  Despite the pregnancy, this patient still can struggle with normal adolescent behaviors and experiences in which risk factors such as poor self-esteem and peer pressure must also be recognized.  It is important to incorporate these techniques into practice so that these risk factors can be identified and help and prevention measures provided (Ball et al., 2015). 

Thirdly, although an adolescent, this patient is pregnant.  Obtaining her health history regarding her pregnancy, any problems or complications thus far, menstrual and gynecologic history, and family history of genetic conditions or pregnancy related complications is vital.  This helps provide a direction for the appointment and future appointments, as well as identification of any health risks currently or potentially in the future (Ball et al., 2015).  Medical conditions such as diabetes or cardiac problems, risks for preterm labor, being pregnant with multiples, or any condition or issue which classifies the pregnancy as high risk, may prompt the need for a provider who cares for high-risk pregnancies (Fuentes, 2018).  Again, while obtaining her health history removal of any physical barriers such as electronic devices will help the patient feel more comfortable during the appointment, especially when talking about any sensitive issues or concerns (Ball et al., 2015). 

Risk Assessment Tool 

A risk assessment screening tool that could be utilized during the interview process with this patient would include the HITS screening tool for domestic violence.  The HITS screening tool includes questions for the patient, which asks if her partner has physically hurt her, insulted or belittled her, threatened her, or screamed at her in the past year (Ball et al., 2015).  As a 16-year-old, female gender, and pregnant, this patient is at an increased risk for intimate partner violence (IPV).  Intimate partner violence can have a significant consequence on an individual’s health.  These negative health risks can include chronic, acute, or fatal effects.  In regards to this particular patient’s pregnant health status, some negative health consequences can include an unintended or unwanted pregnancy, pregnancy complications, or miscarriage or abortion.  Additionally, this patient is at risk for sexually transmitted infections (STIs), sexual dysfunction, vaginal bleeding, vaginal or pelvic infections, multiple sexual partners, are at increased risk of having abusive partners in the future, and less likely to use contraception (World Health Organization, 2012).  It is imperative to ask questions when building a health history in order to assess the patient’s health risks.  Five questions that could be asked of this patient include:  

  • “Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?”  
  • “Do you feel safe at home or in your current relationship?”  
  • “Did you want to, or were you forced or talked into having sex?”  
  • “Is alcohol or drugs part of the problem?”  
  • “Has it gotten worse lately?”  

Answering “yes” to any of these questions warrants further evaluation (Ball et al., 2015). 

 

References 

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s 

guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Fuentes, A. (2018). Medical care during pregnancy. KidsHealth. Retrieved from 

https://kidshealth.org/en/parents/medical-care-pregnancy.html 

World Health Organization. (2012). Understanding and addressing violence against 

women: Health consequences. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/77431/WHO_RHR_12.43_eng.pdf;jsessionid=9B21862A7D4A6F36422173D14595A05E?sequence=1 

 

Building a Health History 

Scenario: 76-year-old Black/African-American male with disabilities living in an urban setting 

 

A Description of the Interview and Communication Techniques for this Patient 

            According to Ball, Dains, Flynn, Soloman, and Stewart (2015), the first meeting of a patient and a clinician sets the tone of the relationship between the two individuals regardless of other dynamics.  However, seeing that this is an elderly patient consideration of cognitive disabilities such as limited vision, hearing loss, and possible deterioration of comprehension skills should be taken into consideration (Ball, Dains, Flynn, Soloman & Stewart, 2015). Sensory loss can make communication and the interview process rather difficult and tedious leading to a mislay of the major reason for the initial visit (Deck et al., 2015). The interview setting would be a quiet room, face to face communication, speaking slowly, clearly, using simple terms with a possible close family member for history assistance. The comprehensive geriatric assessment (CGA) too, would be utilized that give a structured approach to identify, prioritize and manage the disease processes and therapeutic interventions of the elderly (Seematter-Bagnoud & Büla, 2018).  

Explain, Identify, and Justify the Risk Assesment Instrument and Why it Applies to the Chosen Patient 

            When using CGA, the clinician screens the patient for functional impairment asking questions regarding activities of daily living (ADL’s) such as bathing, dressing, toileting, transferring, continence, eating, preparing meals, medication distribution, and transportation (Seematter-Bagnoud & Büla, 2018).  A screening for depression and social isolation due to the significance for depressive disorders on 10-15% of older adults (Seematter-Bagnoud & Büla, 2018).  A screening of cognitive impairment due to the prevalence of dementia in 5% of adults aged 65-70 to 30-40% in 90 years and older (Seematter-Bagnoud & Büla, 2018). A test called the Mini-Cog is used on these patients that is comprised of a three-word recall test within a clock drawing (Doerflinger, 2017).  Impaired cognition is suspected when a patient is unable to recall any or either one or two words and must follow up with neuropsychological testing to rule out dementias or Alzheimers (Doerflinger, 2017).  A screening for sensory impairments such as vision and hearing that can impact communication on specifically how to take a certain medication (Seematter-Bagnoud & Büla, 2018). Screenings for nutritional problems, where malnutrition can m be triggered by medications, chronic illness, socioeconomic and psychological issues (Seematter-Bagnoud & Büla, 2018).  Finally, a fall risk assessment due to one in three persons 65 years and older falls every year with one in ten having significant debilitating injuries (Seematter-Bagnoud & Büla, 2018). The current patient is a prime candidate for this screening tool.  

Five Targeted Risk Assessment Questions 

1.     Do you have difficulties with ADL’s? (ex. bathing, dressing, making meals, taking medications, transportation)  

2.     Can you recall three words in this clock drawing? (Mini-Cog Test) 

3.     In the past two weeks have you had little interest in doing things, feeling down, depressed, or hopeless? 

4.     How is your vision and hearing? (perform an Snellen eye chart trail and whisper in each ear)  

5.     How are your eating habits? Any unexplained weight loss? Do you shop for and prepare your own meals? (body mass index performed) 

6.     Do you have problems with your gait? Do your have stairs in your house? Do you walk with a walker or cane? 

7.     Who do you live with? Do you have someone to take care of you if you get sick? Who can make decisions for you is you were unable to? 

            Overall, the CGA assessment instrument focuses on function-related outcomes, underlying causes, and multiple chronic disorders in older people(Seematter-Bagnoud & Büla, 2018).  CGA reduced disability, extended home-stay, and reduced the institutionalized rate by 20% when intitiated in community dwelling hospitalized older adults (Seematter-Bagnoud & Büla, 2018).  CGA decreased the risk of hospital and nursing home admissions. Finally, for general practice physicians, withCGA medical problems were managed within 12 months of diagnosis which improved quality of care including reductions of falls and quality of life (Seematter-Bagnoud & Büla, 2018).  

 

References 

Ball, J. W., Dains, J, E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to 

            Physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnee, V., L Van 

           Abbema, D, & Buntinx, F, (2015). Geriatric screening tools are of limited value to  

           predict decline in functional status and quality of life: results of a cohort study. BMC  

           Family Practice, 16(30), 1-12. Doi 10.1186/s12875-015-0241-x. Retrieved from  

           http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0241-x 

Doerflinger, D. C. (2017). ConsultGeri. Retrieved from https://consultgeri.org/ 

Seematter-Bagnoud, L., & Büla, C. (2018). Brief assessments and screening for geriatric 

            conditions in older primary care patients: a pragmatic approach. Public Health  

            Reviews, 39(1). doi:10.1186/s40985-018-0086-7 

 

Building a Health History: 76-year-old Black/African-American male with disabilities living in an urban setting 

As a clinician, it is crucial to utilize good communication tools in building the health history of my patient. The communication techniques that I will use while interviewing my client include providing clear responses, listening first before speaking, and asking engaging questions (Koo et al., 2016). The main interview technique that I will use is bridging which will help me keep the process on track.  

For this patient who is living in an urban settlement, I will use the HomeSafety Self-Assessment Tool. This tool is essential in evaluating the several living conditions of older adults and find out if his home is a safe environment considering that he lives with disabilities (Buta et al., 2016). It is difficult for an individual to the age where the homes do not have the required features or even the homeowners have not been doing home maintenance. The tool is also essential since it helps in the identification of all the fall risk in a home environment that further results in improvement in home safety (Tomita et al., 2014).  

The following are the questions that I will ask my client: 

  1. Do you have stairs in your home? If yes how do you manage to move around the house?  
  1. Whom do you live with?  
  1. Have you ever fallen while moving with your wheelchair?  
  1. Do you use any drugs? If yes, which ones?  
  1. Has your disability affected your life in any way? Do you usually need assistance in things like cooking or bathing?  

Trust is usually an essential tool for a patient and a clinician. As a clinician, my main concern is the safety of my client that is why I need to know whom he lives with. Furthermore, I would evaluate activities of daily living which include feeding, bathing., or toileting. If the client lives with someone, then it makes it easier for him to engage in daily activities. However, it is a risk if he uses drugs of has ever fallen since it may result in the development of other health issues. Therefore, living with disabilities is difficult especially with an older adult, and that is the reason Home Safety Self-Assessment Tool-assisted in knowing the issues affecting my client.  

 

 

 

Reference 

Buta, B. J., Walston, J. D., Godino, J. G., Park, M., Kalyani, R. R., Xue, Q. L., … & Varadhan, R. (2016). Frailty assessment instruments: systematic characterization of the uses and contexts of highly-cited instruments. Ageing research reviews, 26, 53-61. 

Koo, L. W., Horowitz, A. M., Radice, S. D., Wang, M. Q., & Kleinman, D. V. (2016). Nurse practitioners’ use of communication techniques: results of a Maryland Oral Health Literacy Survey. PloS one, 11(1), e0146545. 

Tomita, M. R., Saharan, S., Rajendran, S., Nochajski, S. M., & Schweitzer, J. A. (2014). Psychometrics of the Home Safety Self-Assessment Tool (HSSAT) to prevent falls in community-dwelling older adults. American journal of occupational therapy, 68(6), 711-718. 

Interview and Communication Techniques 

            During the interview of a 16-year-old white pregnant teenager living in an inner-city neighborhood, the techniques to build a health history should be thoughtfully and compassionately carried out.  Firstly, it is recommended during any interview that it take place in a comfortable setting.  It is advisable to stray away from equipment or desks/tables unintentionally creating a barrier between the provider and the patient.  The provider should sit eye level with the patient, relaxed, with a calm tone of voice.  These techniques will help the provider establish a relationship with the patient; gaining the patient’s trust, thus obtaining an accurate and thorough health history (Ball, Dains, Flynn, Solomon, & Stewart, 2015). 

Secondly, the patient is an adolescent still.  When the provider introduces him/herself to the patient, anyone accompanying the patient should also be identified and addressed by name.  If there is a parent with the patient, the provider should learn the parent’s name and involve the parent.  However, a patient over the age of seven can typically be a dependable reporter for health information and the patient should be allowed confidentiality and privacy.  Adolescents may be reluctant to disclose certain information in front of a parent and wish to speak with the provider privately.  It is important to honor these wishes yet involve the parent and the patient’s support system in the patient’s care.  Despite the pregnancy, this patient still can struggle with normal adolescent behaviors and experiences in which risk factors such as poor self-esteem and peer pressure must also be recognized.  It is important to incorporate these techniques into practice so that these risk factors can be identified and help and prevention measures provided (Ball et al., 2015). 

Thirdly, although an adolescent, this patient is pregnant.  Obtaining her health history regarding her pregnancy, any problems or complications thus far, menstrual and gynecologic history, and family history of genetic conditions or pregnancy related complications is vital.  This helps provide a direction for the appointment and future appointments, as well as identification of any health risks currently or potentially in the future (Ball et al., 2015).  Medical conditions such as diabetes or cardiac problems, risks for preterm labor, being pregnant with multiples, or any condition or issue which classifies the pregnancy as high risk, may prompt the need for a provider who cares for high-risk pregnancies (Fuentes, 2018).  Again, while obtaining her health history removal of any physical barriers such as electronic devices will help the patient feel more comfortable during the appointment, especially when talking about any sensitive issues or concerns (Ball et al., 2015). 

Risk Assessment Tool 

A risk assessment screening tool that could be utilized during the interview process with this patient would include the HITS screening tool for domestic violence.  The HITS screening tool includes questions for the patient, which asks if her partner has physically hurt her, insulted or belittled her, threatened her, or screamed at her in the past year (Ball et al., 2015).  As a 16-year-old, female gender, and pregnant, this patient is at an increased risk for intimate partner violence (IPV).  Intimate partner violence can have a significant consequence on an individual’s health.  These negative health risks can include chronic, acute, or fatal effects.  In regards to this particular patient’s pregnant health status, some negative health consequences can include an unintended or unwanted pregnancy, pregnancy complications, or miscarriage or abortion.  Additionally, this patient is at risk for sexually transmitted infections (STIs), sexual dysfunction, vaginal bleeding, vaginal or pelvic infections, multiple sexual partners, are at increased risk of having abusive partners in the future, and less likely to use contraception (World Health Organization, 2012).  It is imperative to ask questions when building a health history in order to assess the patient’s health risks.  Five questions that could be asked of this patient include:  

  • “Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?”  
  • “Do you feel safe at home or in your current relationship?”  
  • “Did you want to, or were you forced or talked into having sex?”  
  • “Is alcohol or drugs part of the problem?”  
  • “Has it gotten worse lately?”  

Answering “yes” to any of these questions warrants further evaluation (Ball et al., 2015). 

 

References 

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s 

guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Fuentes, A. (2018). Medical care during pregnancy. KidsHealth. Retrieved from 

https://kidshealth.org/en/parents/medical-care-pregnancy.html 

World Health Organization. (2012). Understanding and addressing violence against 

women: Health consequences. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/77431/WHO_RHR_12.43_eng.pdf;jsessionid=9B21862A7D4A6F36422173D14595A05E?sequence=1 

3 months ago  

SHERYL MELVIN  

RE: Discussion Week 1 INITIAL POST  

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Top of Form 

NURS 6512C 

WEEK 1  

11/28/2018 

INITIAL POST 

Building a Health History 

Scenario: 76-year-old Black/African-American male with disabilities living in an urban setting 

 

A Description of the Interview and Communication Techniques for this Patient 

            According to Ball, Dains, Flynn, Soloman, and Stewart (2015), the first meeting of a patient and a clinician sets the tone of the relationship between the two individuals regardless of other dynamics.  However, seeing that this is an elderly patient consideration of cognitive disabilities such as limited vision, hearing loss, and possible deterioration of comprehension skills should be taken into consideration (Ball, Dains, Flynn, Soloman & Stewart, 2015). Sensory loss can make communication and the interview process rather difficult and tedious leading to a mislay of the major reason for the initial visit (Deck et al., 2015). The interview setting would be a quiet room, face to face communication, speaking slowly, clearly, using simple terms with a possible close family member for history assistance. The comprehensive geriatric assessment (CGA) too, would be utilized that give a structured approach to identify, prioritize and manage the disease processes and therapeutic interventions of the elderly (Seematter-Bagnoud & Büla, 2018).  

Explain, Identify, and Justify the Risk Assesment Instrument and Why it Applies to the Chosen Patient 

            When using CGA, the clinician screens the patient for functional impairment asking questions regarding activities of daily living (ADL’s) such as bathing, dressing, toileting, transferring, continence, eating, preparing meals, medication distribution, and transportation (Seematter-Bagnoud & Büla, 2018).  A screening for depression and social isolation due to the significance for depressive disorders on 10-15% of older adults (Seematter-Bagnoud & Büla, 2018).  A screening of cognitive impairment due to the prevalence of dementia in 5% of adults aged 65-70 to 30-40% in 90 years and older (Seematter-Bagnoud & Büla, 2018). A test called the Mini-Cog is used on these patients that is comprised of a three-word recall test within a clock drawing (Doerflinger, 2017).  Impaired cognition is suspected when a patient is unable to recall any or either one or two words and must follow up with neuropsychological testing to rule out dementias or Alzheimers (Doerflinger, 2017).  A screening for sensory impairments such as vision and hearing that can impact communication on specifically how to take a certain medication (Seematter-Bagnoud & Büla, 2018). Screenings for nutritional problems, where malnutrition can m be triggered by medications, chronic illness, socioeconomic and psychological issues (Seematter-Bagnoud & Büla, 2018).  Finally, a fall risk assessment due to one in three persons 65 years and older falls every year with one in ten having significant debilitating injuries (Seematter-Bagnoud & Büla, 2018). The current patient is a prime candidate for this screening tool.  

Five Targeted Risk Assessment Questions 

1.     Do you have difficulties with ADL’s? (ex. bathing, dressing, making meals, taking medications, transportation)  

2.     Can you recall three words in this clock drawing? (Mini-Cog Test) 

3.     In the past two weeks have you had little interest in doing things, feeling down, depressed, or hopeless? 

4.     How is your vision and hearing? (perform an Snellen eye chart trail and whisper in each ear)  

5.     How are your eating habits? Any unexplained weight loss? Do you shop for and prepare your own meals? (body mass index performed) 

6.     Do you have problems with your gait? Do your have stairs in your house? Do you walk with a walker or cane? 

7.     Who do you live with? Do you have someone to take care of you if you get sick? Who can make decisions for you is you were unable to? 

            Overall, the CGA assessment instrument focuses on function-related outcomes, underlying causes, and multiple chronic disorders in older people(Seematter-Bagnoud & Büla, 2018).  CGA reduced disability, extended home-stay, and reduced the institutionalized rate by 20% when intitiated in community dwelling hospitalized older adults (Seematter-Bagnoud & Büla, 2018).  CGA decreased the risk of hospital and nursing home admissions. Finally, for general practice physicians, withCGA medical problems were managed within 12 months of diagnosis which improved quality of care including reductions of falls and quality of life (Seematter-Bagnoud & Büla, 2018).  

 

References 

Ball, J. W., Dains, J, E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to 

            Physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnee, V., L Van 

           Abbema, D, & Buntinx, F, (2015). Geriatric screening tools are of limited value to  

           predict decline in functional status and quality of life: results of a cohort study. BMC  

           Family Practice, 16(30), 1-12. Doi 10.1186/s12875-015-0241-x. Retrieved from  

           http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0241-x 

Doerflinger, D. C. (2017). ConsultGeri. Retrieved from https://consultgeri.org/ 

Seematter-Bagnoud, L., & Büla, C. (2018). Brief assessments and screening for geriatric 

            conditions in older primary care patients: a pragmatic approach. Public Health  

            Reviews, 39(1). doi:10.1186/s40985-018-0086-7 

 

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3 months ago  

Rosanie Estima  

discussion week 1  

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Building a Health History: 76-year-old Black/African-American male with disabilities living in an urban setting 

As a clinician, it is crucial to utilize good communication tools in building the health history of my patient. The communication techniques that I will use while interviewing my client include providing clear responses, listening first before speaking, and asking engaging questions (Koo et al., 2016). The main interview technique that I will use is bridging which will help me keep the process on track.  

For this patient who is living in an urban settlement, I will use the HomeSafety Self-Assessment Tool. This tool is essential in evaluating the several living conditions of older adults and find out if his home is a safe environment considering that he lives with disabilities (Buta et al., 2016). It is difficult for an individual to the age where the homes do not have the required features or even the homeowners have not been doing home maintenance. The tool is also essential since it helps in the identification of all the fall risk in a home environment that further results in improvement in home safety (Tomita et al., 2014).  

The following are the questions that I will ask my client: 

  1. Do you have stairs in your home? If yes how do you manage to move around the house?  
  1. Whom do you live with?  
  1. Have you ever fallen while moving with your wheelchair?  
  1. Do you use any drugs? If yes, which ones?  
  1. Has your disability affected your life in any way? Do you usually need assistance in things like cooking or bathing?  

Trust is usually an essential tool for a patient and a clinician. As a clinician, my main concern is the safety of my client that is why I need to know whom he lives with. Furthermore, I would evaluate activities of daily living which include feeding, bathing., or toileting. If the client lives with someone, then it makes it easier for him to engage in daily activities. However, it is a risk if he uses drugs of has ever fallen since it may result in the development of other health issues. Therefore, living with disabilities is difficult especially with an older adult, and that is the reason Home Safety Self-Assessment Tool-assisted in knowing the issues affecting my client.  

 

 

 

Reference 

Buta, B. J., Walston, J. D., Godino, J. G., Park, M., Kalyani, R. R., Xue, Q. L., … & Varadhan, R. (2016). Frailty assessment instruments: systematic characterization of the uses and contexts of highly-cited instruments. Ageing research reviews, 26, 53-61. 

Koo, L. W., Horowitz, A. M., Radice, S. D., Wang, M. Q., & Kleinman, D. V. (2016). Nurse practitioners’ use of communication techniques: results of a Maryland Oral Health Literacy Survey. PloS one, 11(1), e0146545. 

Tomita, M. R., Saharan, S., Rajendran, S., Nochajski, S. M., & Schweitzer, J. A. (2014). Psychometrics of the Home Safety Self-Assessment Tool (HSSAT) to prevent falls in community-dwelling older adults. American journal of occupational therapy, 68(6), 711-718. 

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3 months ago  

Edith Abraham  

Discussion Post WK1 Health History  

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                                                                              Building a Health History 

                       76-year-old Black/African-American male with disabilities living in an urban setting 

                                                             Interview and Communication Techniques 

         Asking the right open-ended questions and waiting for the response without interruption can help the patient to provide you with useful information about what is impacting their health and quality of life. So, for the above patient, I would begin the interview with the open-ended question, such as “How have you been feeling lately?’ and allow the patient ample opportunity to answer the question without interruption.  It allows the patient to express themselves without bias or leading from the provider and establish rapport (Hashim, 2017). Engaging in active listening communicates to the patient that you have respect for them and establishes trust. Trust allows the patient to be comfortable in sharing and forthcoming about feelings or emotional needs, concerns, expectations, and ideas about their health that might be underlying or outside of the reason for their visit (Ball, Dains, Flynn, Solomon, & Stewart, 2015; Hashim, 2017; Ingram,2017).  Targeted or more focused questions can follow the open-ended questions to seek clarity of issues.  Expressing or communicating empathy about the patient’s experience or emotions facilitates the therapeutic relationship because it shows understanding, support, and respect for the patient (Ball et al., 2017; Hashim, 2017). Avoiding the use of medical jargon and avoiding overwhelming the patient with medical information, helps to keep the interview clear and coherent for both the provider and the patient (Hashim, 2017; Ingram, 2017).  Seeking to understand and accommodate for language barriers, disabilities, or culture or religious practices if possible, establishes trust and keeps the interview clear of any misunderstanding and help to pick up on any other silent, sudden, or distressing symptoms that could have otherwise be missed (Ball et al.,2015).  Elderly patients may have hearing loss, or some cognitive delay or memory loss that may necessitate for the extra time needed to convey messages or questions to the patient and receive an adequate response from the patient (Ball et al., 2015). 

                                                                                     Risk Assessment Instrument 

          Obtaining a functional health assessment on all elderly patients is recommended but especially for those with disabilities or physical limitations (Ball et al., 2017; Jankowska, Jankowski, & Rudnicka-Drożak, 2018).  This assessment would be appropriate for the patient because he is in the elder or older adult population (76 years of age) and he has disabilities. The functional status of elderly patients, especially for those with existing limitations,   is significant because it details everyday safety and quality of life. A functional assessment can facilitate both the provider and patient to view their health objectively. A functional evaluation can point out the onset of frailty, loss of cognitive abilities, or senses. The earlier these situations can be determined,  then both the provider and patient can develop manageable plans of care to maintain optimal health and quality of life (Ball et al., 2017; Jankowska, Jankowski, & Rudnicka-Drożak, 2018). 

                                                                                       Five Targeted Questions 

1.      Tell me about your living situation. 

2.      Has this happened before? If so how was it treated in the past? Resolutions? 

3.      When did this start? 

4.      Is there illness in the family? 

5.      Do you have a healthcare surrogate? 

                                            

                                                                                             Conclusion 

       Building a complete health history is an essential element or tool in trying to provide holistic care to patients.  The health history allows the practitioner to view how the condition(s) or illness(s) affects the physical and mental quality of life for the patient.  The comprehensive history allows for the therapeutic relationship between provider and patient to grow and expand.  Each patient is different and the patient views and experiences the world differently. So, building the health history must be approached differently for each patient.  Changes occur to people in different stages and at different rates of the life cycle.  And patients have different needs based on culture, religion, sexual orientation, and disabilities. Providers must not have a one size fits all attitude. But to consider what they know and don’t know about the patient’s disability, sexual orientation, race, gender, and age to facilitate both effective verbal and nonverbal communication that promotes the patient to be forthcoming about their family history, lifestyle, medical history, and health concerns which is vital for accurate diagnosis and treatment of illness or disease (Ball et al., 2015; Hashim, 2017; Ingram, 2017).  

                                                     

                                                                                             References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Hashim, M. J. (2017). Patient-Centered Communication: Basic Skills. American Family Physician, 95(1), 29–34. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=28075109&site=eds-live&scope=site 

Ingram, S. (2017). Taking a comprehensive health history: learning through practice and reflection. British Journal of Nursing, 26(18), 1033. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=125696139&site=eds-live&scope=site 

 Jankowska, P., Jankowski, K. & Rudnicka-Drożak, E.  (2018). Functional capacity of elderly and its assessment. Journal of Education, Health and Sport, 8, (7), 509-515 DOI: https://doi-org.ezp.waldenulibrary.org/10.5281/zenodo.1344436 

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Week 1: Building a Health History  

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Week 1: Building a Health History 

INITIAL POST 

Interview and Communication Techniques 

             The patient that I chose for this week’s discussion was a 16-year-old white pregnant teenager living in an inner-city neighborhood. A comprehensive history and physical are an essential part of a patient’s medical record (Sullivan, 2019). The health history can change based on what stage the patient is in and their age, it also helps in identifying health risks and conditions and can be used as a guide in health maintenance (Sullivan, 2019). Effective communication is vital in gathering a patient’s comprehensive health history. According to Ball, Dains, Flynn, Solomon, and Stewart (2015) effective communication with patients is based around establishing a connection, having courtesy, ensuring comfort, and providing confirmation that there has been a clear understanding. The interview should take place in a position that there is nothing in between the patient and I and allows for easy eye contact without any distractions to ensure that the patient feels that her health and concerns are my priority (Ball et al., 2015). I would also make sure to explain further any questions that may be sensitive as they may be difficult for the patient to discuss; in this case, sensitive issues would be pertinent to address (Ball et al., 2015). Ball et al. (2015) suggest the use of pre-visit questionnaires or screening tools to help facilitate further discussion throughout the visit of sensitive issues that may be difficult for an adolescent to express. I also would be aware potential variables that may affect the patient’s health such as issues with school, peer pressure, and the stress of adolescent pregnancy (Ball et al., 2015). 

Risk Assessment Instrument 

             The risk assessment tool that I would select to use would be the HEEADSSS screening tool. HEEADSSS which stands for home, education/employment, eating, activities, drugs and alcohol, sexuality, suicidality, and safety; is a screening tool that assesses for risky behaviors in adolescents (Smith & McGuinness, 2017). According to Smith and McGuiness (2017) identifying risky behaviors early on can help prevent risky behaviors in the future. I chose this tool as it not only addresses concerns that are common in adolescents, but it also addresses concerns that could have consequences for the patient’s well-being and pregnancy (Ball et al., 2015). The patient may not have a safe place to stay, financial means for taking care of herself or the baby, or food to eat, the patient could also be or have been in an abusive relationship that may have resulted in the pregnancy. I think HEEADSSS would be an excellent tool that could help in identifying sensitive issues and concerns that are not only relevant to the adolescent, but also behaviors that could put the patient’s pregnancy at risk as well. 

Five Targeted Questions 

             The five targeted questions that I would ask my selected patient to assess her health risks are as follows: 

  1. What type of emotional and financial support do you have?  
  1. What is your relationship like with your parents?  
  1. Tell me about how school is going for you.  
  1. Tell me about how you are feeling and your thoughts on your pregnancy.  
  1. Tell me, if anything, what you feel like is not going well.  

References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Smith, G. L., & McGuinness, T. M. (2017). Adolescent psychosocial assessment the HEEADSSS. Journal of Psychological Nursing and Mental Health Services, 55(5), 24–27.  

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

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Week 1: Building a Comprehensive Health History  

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The patient I chose was the 76-year-old Black/African-American male with disabilities living in an urban setting. 

 

​The description of the above patient prepares me to interact with an older adult, which may require me to speak clearly and slowly, maintain good eye contact while remaining face-to-face, and ask short but not leading questions (Ball, Dains, Flynn, Solomon, & Stewart, 2015). As we are from different generations and cultures I will not use any jargon or slang. I would respect and I am sure come to realize the amount of history and knowledge this man has to offer. In addition, I would tend to believe that he may have a lengthy past medical and surgical history. The other issue may be his medications and whether or not they are correct, recent, duplicates, and any at high risk (Ball et al., 2015). Does he take any vitamins, herbal remedies, or over-the-counter remedies that he has been taking for years and does he understand why or who encouraged him to takethem. The other issue would be determining his disabilities and discovering if and to what extent does he have anycognitive, emotional, and physical complications (Ball et al., 2015). If there are cognitive deficits, it may be beneficial to include family members to fill in areas where the patient has difficulty remembering (Ball et al., 2015). 

 

​Health risk assessments are an important part of a patient’s healthy state due to its purpose of discovering the patient’s risk for developing common chronic diseases andallows the PMHNP to develop personalized care plans (Wu, & Orlando, 2015). Another risk assessment instrument is the abbreviated comprehensive geriatric assessment (aCGA), which examines four items from the Geriatric Depression Scale, three items from the ADL, four items from IADL, and four items from the Mini Mental State Examination (Deck, Akker, Daniels, DeJonge, Bulens, Tjan-Heihnen, Van Abbema, & Buntinx, 2015). This test, although abbreviated from four more comprehensive tests, provides a quick snapshot of the patient’s needs and what type of assistance the patient might need. On a similar plane, I would alter the risk assessment instrument used for functional assessments to determine the patient’s ability to perform ADLs and IADLs by screening the patient when the patient initially ambulates into the office and observing his attempt to get into and out of his chair before and after the visit. How stable is he and can he perform these activities independently and safely. As in home care, it is imperative that we discover how safe and capable the patient is at caring for himself as part of the Review of Systems (ROS) (Ball et al., 2015). It is just as important to determine how accessible sources of transportation are for the patient in order to obtain groceries, medical resources, and social interactions in his urban setting. 

 

Based on the patient coming to a PMHNP for an assessment I would ask him the following five targeted questions:  

 

​1. Do you feel that your life is empty? 

​2. Do you often feel helpless? 

​3. Who do you count on for being available to you at anytime? 

​4. I would ask the patient to count backward by 7 and if he does not perform then I would ask him to spell WORLD backwards (DLROW). I would ​​​also ask him to write a sentence. 

​5. How do you obtain your medications and groceries? 

 

References 

 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Esevier Mosby. 

 

Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnen, V., L Van Abbema, D. & Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: results of a cohort study. BMC Family Practice, 16(30), 1-12. Doi:10.1186/s12875-015-0241-x. 

 

Wu, R. R. & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: barriers and benefits. Post Grad Medical Journal, 91(1079), 508-513. Doi:10.1136/postgradmedj-2014-133195. 

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3 months ago  

chinnyeer madison  

Main Post. 76 years old Black/African-American male with disabilities  

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     Main Post. As the healthcare industry continues to expand and become more innovated with the enhancement of technology, developing a clinician-patient relationship has become tainted. Unfortunately, in the world of technology, communication can be obscured behind computer screens and smart phones. The clinician-patient relationship has a significant effect on the outcome rather positive or negative. The clinician-patient relationship must be composed of both emotional care and cognitive care (Kelley, Kraft-Todd, Schapira, Kossowsky, & Riess, 2014). The patient and the clinician must develop a mutual trust and respectful relationship that creates an environment that both the clinician and the patient can learn, understand, and gain knowledge from one another.  The first encounter is an essential part of developing a successful patient-clinician relationship (Ball, Danis, Flynn, Solomon, & Stewart, 2015). 

     My patient is a 76- year old Black/African-American male with disabilities living in an urban setting. In today’s time, life expectancy has increased with the projected U.S. population of 65 years or older to reach approximately 23.5% or 98 million in 2060, according to Healthy People 2020 (Healthy People 2020, 2018). The life expectancy may have increased, but the aging process still manifests. Many older adults will experience changes both mentally and physically but having disabilities can make these changes challenging. 

     My first encounter with this patient is to establish a relationship that is built on trust and is non-judgmental. As a clinician, my priority will make sure he is safe and that he feels safe. Falls are very common among older adults and is the leading cause of injuries that are treated in the emergency room (Healthy People 2020, 2018).  Falls can be preventable if all risk factors are address (Healthy People 2020, 2018). The next thing I need to address is his living arrangement. Urban areas are developed with houses and apartments. With his disabilities, living alone may be an issue. If family members are present or local, implementing them in his plan of care will be beneficial. The third part of his care is addressing any chronic diseases that he may be dealing with. Being a Black/African- American male put him at a higher risk factor for developing diabetes, hypertension, and obesity than White Americans.  (American Psychological Association, 2018). Factors that contribute to this disparity are poverty, segregated communities with fewer health-promoting resources, poor education, unemployment, discrimination and less access to quality health care (American Psychological Association, 2018). 

     In the first encounter, I will use the functional assessment tool to gain as much information as I can to assess his immediate needs, as well as his ability to function as independently as possible with his disabilities. The five questions I will be asking the patient are as follows: 1. Do you feel safe at home? 2. What can you do independently without any assistance? 3. Do you have any support that lives locally, rather it be family members or close friends that can assist you? 4. Do you need assistance with transportation to and from doctor visits, grocery shopping, etc.? 5.  Will you need assistance for daily living care and/or household chores like laundry, washing dishes, and cooking? 

References 

American Psychological Association. (2018). Older Adults and Health and age-related changes. Retrieved from American Psychological Association: https://www.apa.org/pi/aging/resources/guides/older.aspx. 

Ball, J., Danis, J., Flynn, J., Solomon, B., & Stewart, R. (2015). The History and Interviewing Process. In J. Ball, J. Danis, J. Flynn, B. Solomon, & R. Stewart, Seidel’s Guide to Physical Examination (pp. 1-20). Canada: Elsevier. 

Healthy People 2020. (2018, November 28). HealthyPeople.gov. Retrieved from Office of Disease, Prevention and Health Promotion: https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults 

Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014, April 9). The Influence of the Patient-Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLOS One, 9(4), e94207. doi: 10.1371/journal.pone.0094207 

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3 months ago  

Sheila Jeudy  

Building a health history  

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NURS 6512C: Advanced Health Assessment and Diagnostic Reasoning 

Week 1 Discussion 

INITIAL POST 

Building a Health History 

Communication and interview techniques used for building a health history for a 76-year-old Black/African-American male with disabilities living in an urban setting should include addressing any sensory losses by facing the patient, speaking slowly and clearly; and allowing the patient additional time to answer questions if they experience memory loss for recent events (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Targeted questions should focus on any ongoing conditions the patient has as well as their current ability to care for themselves, identifying the community and family support available to the patient, plans for advance directives or designating a healthcare proxy/ power of attorney for health decisions. A functional assessment should also be conducted on elderly patients to assess their ability to perform activities of daily living (ADLs) and care for themselves. Patients with disabilities should be involved in obtaining their health history to the limit of their capabilities, but family members, as well as medical records, should also be consulted (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Potential health-related risks for this patient depend on their health status including any chronic conditions, and the nature of their disability and its limitations. 

A risk assessment tool that would be appropriate for this patient would be the Vulnerable Elders Survey- 13 (VES-13). This survey assesses an individual’s risk of death or functional decline. This screening tool consists of 13 questions regarding elderly “peoples’ ability to perform six physical and five functional activities, their self-rated health, and their age” (Deckx, van den Akker, Daniels, De Jonge, Bulens, Tjan-Heijnen, van Abbema, & Buntinx, 2015, p.4). The VES-13 tool has been found to be a positive predictor of health outcomes over a 5-year period in the elderly population making it a useful tool for healthcare providers to use to make clinical decisions (Buta, Walston, Godino, Park, Kalyani, Xue, Bandeen-Roche, & Varadhan, 2015). 

Targeted questions appropriate for this patient that should be asked to begin building a health history should include: 

  1. Have you noticed or has anyone else notice any mental status changes? (i.e., memory or cognitive function decline)  
  1. Have you noticed any changes to your skin? (i.e., new rashes, lesions, moles, etc.)  
  1. Have you experienced any difficulty breathing while performing routine activities?  
  1. Have you experienced any decrease in your ability to move around/ walk?  
  1. Have there been any changes in your gait or balance? Any recent slips or falls?  

 

 

References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby 

Buta, B. J., Walston, J. D., Godino, J. G., Park, M., Kalyani, R. R., Xue, Q. L., Bandeen-Roche, K., & Varadhan, R. (2015). Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing research reviews, 26, 53-61. doi: 10.1016/j.arr.2015.12.003 

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C., van Abbema, D. L., & Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: results of a cohort study. BMC family practice, 16(1), 30. doi: https://doi.org/10.1186/s12875-015-0241-x 

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NURS 6512- Advanced Assessment and Diagnostic Reasoning  

INITIAL POST 

Building a Comprehensive Health Assessment 

The health assessment is an essential tool that is needed to make accurate diagnoses and treatment of patients who are suffering from illness.  Therefore there needs to be a fostering of the relationship between the clinician and the patient. A relationship between the clinician and patient will place both parties at ease, build trust and empower the patient. There are certain factors that the clinician must take into consideration when completing a health assessment, such as gender, age, ethnicity, and environment ( Ball, Dains, Flynn, Solomon, & Stewart, 2015, p. 2).   According to Walden’s University Website (2018), these are some of the steps that clinician needs to take when completing a physical assessment; actively listening to what the patient is saying, this is done by completely comprehend what is being said by the patient both verbally and non-verbally. Asked guiding questions which will encourage the patient to continue to speak; pay attention to non-verbal communication from the patient; being empathic, validating the patients feeling and providing reassurance, summarization of what the patient said and lastly empowering the patient but letting the individual aware of what the next steps are going to be.  

            The case that is going to be discussed is the pregnant 16 years old white female who is pregnant and living in an inner-city neighborhood. Adolescent’s pregnancy is a major issue in the United States, especially amongst minority groups. Teenage pregnancy continues to play an instrumental role in high school dropout. Teenage pregnancy is a potential threat that may affect students’ academic, personal and social involvement (McGaha-Garnett, 2013).  Adolescent mothers may struggle to balance the role of parenting with social relationships and academia. Mothers who lack social support are less likely to face and overcome their challenges McGaha-Garnett, 2013). There are several risks factors that this teenager face first there is the fact that she is pregnant at such a young age, which might lead to her being unable to complete high school. Secondly, there is the fact that she is living in an inner-city community and may not have access to healthcare. Due to these huge risks factors that this teenage face,  it is imperative that when the nursing is performing the health assessment that it is conducted in a non-judgmental manner. The clinician needs to be aware of his or her cultural beliefs, faith, and conscience when conducting the health assessment with this teenager because they can lead to being judgmental towards the pregnant teen ( Ball, et al., 2015, p. 2).   

The student believes that the best way to initiate the health assessment on the pregnant teen is to do it a patient-centered manner, in doing so this will immediately empower the teen when she is asked about what would she like the clinician to do for her during the visit? In doing so the clinician will be responding to the wants, needs, and preference and showing respect (Ball at et.,2015).  Prior to starting the assessment, it is important for the clinician to also ask the teen how would she like to be addressed and the clinician should introduce him or herself and explain his or her roles.  The assessment should be done in privacy and allowing enough time for discussion and questions. There should be assured of confidentiality unless there is an imminent danger to the teen and others. The clinician should also have available resources for the teen if needed. The  CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) tool is going to be used to conduct the assessment because of the fact that this tool is also able to asses for alcohol and substance use ((U.S. Department of Health and Human Services (HHS), 2015).   Some of the questions that I would ask the pregnant teen are; 

  1. Where are living now and with whom?  
  1. Does your family have enough money to pay for rent, food, heat and other things that you all need?  
  1. Do you feel safe in your neighborhood?  
  1. Have you ever use any illegal drugs and alcohol in the past year?  
  1. Are you afraid that someone in your family or any person you know might hurt you?  
  1. Are you ever forced to take place in unwanted sexual activities?  
  1. Have you ever been in any legal problems with police or the law in the past year?  
  1. Are you in school? If not what do you do in the day?  
  1. Do you have a doctor’s office, clinic or healthcare center close by that you can go too whenever you are sick?  
  1. Do you have health insurance?  
  1. Do you have access to transportation?  

Through health, the assessment must be conducted on this pregnant teen to find out what are the risk factors to unborn child and patient. The clinician needs to ensure that there are adequate resources in place to provide support to the teen.  

References  

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to  

physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

McGaha-Garnett, V( 2013).  Needs assessment for adolescent mother: building resiliency and  

student success towards high school completion. Retrieved from https://www.counseling.org/resources/library/VISTAS/2008-V-Print-complete-PDFs-for-ACA/McGaha_Article_2.pdf 

U.S. Department of Health and Human Services. (2015). The health and well-being of children  

in rural areas: a portrait of the nation 2011-2012. Retrieved from https://mchb.hrsa.gov/nsch/2011-12/rural-health/pdf/rh_2015_book.pdf 

Walden University Website (2018). Effective nursing health assessment interview techniques.  

Retrieved from  

https://www.waldenu.edu/online-bachelors-programs/bachelor-of-science-in-nursing/resource/effective-nursing-health-assessment-interview-techniques 

 

 

Rubric Detail  

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Content 

Name: NURS_6512_Week_1_Discussion_Rubric 

  Outstanding Performance   Excellent Performance   Competent Performance   Proficient Performance   Room for Improvement  
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.  
Points Range: 44 (44%) – 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.

supported by at least 3 current, credible sources 

Points Range: 40 (40%) – 43 (43%)  

Responds to the discussion question(s)

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

75% of post has exceptional depth and breadth

supported by at least 3 credible references 

Points Range: 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 post has exceptional depth and breadth

supported by at least 3 credible references 

Points Range: 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.

post is cited with fewer than 2 credible references 

Points Range: 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 1 or no credible references 

Main Posting:
Writing  
Points Range: 6 (6%) – 6 (6%)  

Written clearly and concisely

Contains no grammatical or spelling errors

Fully adheres to current APA manual writing rules and style 

Points Range: 5.5 (5.5%) – 5.5 (5.5%)  

Written clearly and concisely

May contain one or no grammatical or spelling error

Adheres to current APA manual writing rules and style 

Points Range: 5 (5%) – 5 (5%)  

Written concisely

May contain one to two grammatical or spelling error

Adheres to current APA manual writing rules and style 

Points Range: 4.5 (4.5%) – 4.5 (4.5%)  

Written somewhat concisely

May contain more than two spelling or grammatical errors

Contains some APA formatting errors 

Points Range: 0 (0%) – 4 (4%)  

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  
Points Range: 10 (10%) – 10 (10%)  

Meets requirements for timely and full participation

posts main discussion by due date 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

Does not meet requirement for full participation 

First Response:

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

Points Range: 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 

Points Range: 8.5 (8.5%) – 8.5 (8.5%)  

Response exhibits critical thinking and application to practice settings 

Points Range: 7.5 (7.5%) – 8 (8%)  

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

Points Range: 6.5 (6.5%) – 7 (7%)  

Response is on topic, may have some depth 

Points Range: 0 (0%) – 6 (6%)  

Response may not be on topic, lacks depth 

First Response:
Writing  
Points Range: 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 

Points Range: 5.5 (5.5%) – 5.5 (5.5%)  

Communication is professional and respectful to colleagues

Response to faculty questions are 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 

Points Range: 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 

Points Range: 4.5 (4.5%) – 4.5 (4.5%)  

Responses posted in the discussion may lack effective professional communication

Response to faculty questions are somewhat answered if posed

Few or no credible sources are cited 

Points Range: 0 (0%) – 4 (4%)  

Responses posted in the discussion lack effective

Response to faculty questions are missing

No credible sources are cited 

First Response:
Timely and full participation  
Points Range: 5 (5%) – 5 (5%)  

Meets requirements for timely and full participation

posts by due date 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

Does not meet requirement for full participation 

Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.  
Points Range: 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 

Points Range: 8.5 (8.5%) – 8.5 (8.5%)  

Response exhibits critical thinking and application to practice settings 

Points Range: 7.5 (7.5%) – 8 (8%)  

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

Points Range: 6.5 (6.5%) – 7 (7%)  

Response is on topic, may have some depth 

Points Range: 0 (0%) – 6 (6%)  

Response may not be on topic, lacks depth 

Second Response:
Writing  
Points Range: 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 

Points Range: 5.5 (5.5%) – 5.5 (5.5%)  

Communication is professional and respectful to colleagues

Response to faculty questions are 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 

Points Range: 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 

Points Range: 4.5 (4.5%) – 4.5 (4.5%)  

Responses posted in the discussion may lack effective professional communication

Response to faculty questions are somewhat answered if posed

Few or no credible sources are cited 

Points Range: 0 (0%) – 4 (4%)  

Responses posted in the discussion lack effective

Response to faculty questions are missing

No credible sources are cited 

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

Meets requirements for timely and full participation

Posts by due date 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

NA 

Points Range: 0 (0%) – 0 (0%)  

Does not meet requirement for full participation 

Total Points: 100  

Name: NURS_6512_Week_1_Discussion_Rubric