NURS 6512 Building a Comprehensive Health History Paper
NURS 6512 Building a Comprehensive Health History Paper
Upon establishing a relationship and building a comprehensive health history, one must understand the importance of a thorough history document. This document is often used as the basis for the entire course of medical management for a patient (Sullivan, 2012). Everyone has a story, and the heath history document should paint an up-to-date and accurate account of the patient’s medical history and a comprehensive physical examination. Any professional that reads the health history document should have a good overview of that patient.
According to Ball, Dains, Flynn, Solomon, & Stewart (2015), the initial meeting between the clinician and the patient sets the tone in the relationship for success, allows the patient to voice concerns, identifies expectations for a good outcome, and to build a partnership in one’s health care. For this week’s discussion, the role of a clinician when building a comprehensive health history with a 16-year old white pregnant teenager living in an inner- city neighborhood will be identified. In addition, review of communication techniques and a risk assessment tool is used with five or more targeted questions that could be asked in this particular situation.
Interview and Communication Techniques
Adolescents is a time between childhood and adulthood where risky behaviors are experimented and where privacy and confidentiality are important to be less hesitant in discussing their concerns (Ball, et.al., 2015). Effective communication with adolescents requires seeing the patient alone, tailoring the discussion to the individual patient, and understanding the role of the parents with confidentiality (Ham, & Allen, 2012). According to Thompson (2010), obtaining a necessary ‘social history’ of each teenager can help to gain vital information about their relationships, assess the needs of the individual, and identify possible problems throughout the pregnancy. There are a number of issues relevant to teenage parents, such as; age, emotional maturity, relationship with parents/partner, educational needs, looked after children, social situation, and supporting young fathers-to-be (Thompson, 2010). The social history is a series of detailed questions creating the basis of the assessment and care plan. The care plan and assessment information is updated throughout the pregnancy and the plan is altered as the situation demands (Thompson, 2010).
Questions should be open-ended so that feedback is prompted, yet, declining to answer should be acceptable as well (Ball, et.al., 2015). For questions that are answered, further investigation can be encouraged to continue the evaluation of the situation. In addition, a screening tool or questionnaire at the pre-visit stage can also encourage a non-forced conversation by silently writing the concern rather than verbalizing the concern (Ball, et.al., 2015). Questions should pertain to thorough evaluation of her partner(s), sexually transmitted infection (STI) history, last menstrual cycle, medical history, previous gynecological visits, social/personal history (including current/previous smoking, drug or alcohol use), family history, and current outlook on the pregnancy. A time for the patient to ask any questions or express any concerns should be followed up, so that the patient is still involved and can feel in control and knowledgeable of the situation. A full head to toe assessment should be completed, including fetal heart tones. The patient-provider relationship should be respectful, useful, and effective with honest responses, making good eye contact, and maintaining non-judgmental respect of wishes.
Risk Assessment Instruments
As above, obtaining a social history can not only assess risky behaviors, discussing general social behaviors can also help to open the door to a better patient-provider relationship. The use of the screening tools HEEADSSS and PACES can guide adolescent issues such as sex, drugs, smoking, alcohol, peer pressure, home environment, and school (Ball, et al., 2015). The answers to these questions can help the provider obtain the knowledge and readiness of the patient’s needs for further educational needs and assistance from the provider (Ball, et al., 2015).
Health-Related Risk Potential
Other situations may arise that can be detrimental health concerns for the patient and the unborn child. Due to age, teenagers are at risk for not obtaining adequate prenatal care. This screens for medical problems in both mother and baby, monitors the baby’s growth, and deals quickly with any complications that arise. Prenatal vitamins with folic acid (ideally taken before getting pregnant) are essential to help prevent certain birth defects, such as neural tube defects (CDC, 2010). Pregnant teens have a higher risk of getting high blood pressure (pregnancy-induced hypertension) than pregnant women in their 20s or 30s (CDC, 2010, NURS 6512 Building a Comprehensive Health History Paper). They also have a higher risk of preeclampsia, which is a dangerous medical condition that combines high blood pressure with excess protein in the urine, swelling of a mother’s hands and face, and organ damage (CDC, 2010). In addition, pregnant teens may be at higher risk of postpartum depression (CDC, 2010).
Several target questions may be used to help determine risks and build an up-to-date accurate health history. These questions may also help to obtain sexual history, any violence or potential violence, family support, and any other potential high risk endeavors that may harm the fetus or the patient. The questions below may be asked in a different sequence depending on the conversation and situation.
- When was your last menstrual cycle?
- Was this a planned pregnancy?
- Have you had any previous pregnancies?
- What is your current outlook on this pregnancy?
- How many sex partners have you had?
- Do you drink alcohol, smoke, or do recreational drugs? If so, how often?
- Do you have a good relationship with your parents?
- Have you ever been ‘in care’ or a ‘looked after child’?
- How does your parents feel about you being pregnant?
- Do you think your parents will support you?
- How are you doing in school?
- Do you have any questions for me?
Encouragement and education can go a long way with a teenager who is pregnant. A practitioner that can listen and treat to the best of their ability without judgement is one who has built a relationship on trust, honesty, and respect with the patient, no matter the age or circumstance. Thus, obtaining a health history that is accurate and reflects the patient’s situation, identifying the possible risk factors or complications that could arise.
References for NURS 6512 Building a Comprehensive Health History Paper
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.
Center for Disease Control and Prevention (CDC). (2010). Reproductive Health: Teen Pregnancy. Retrieved from: http://www.cdc.gov/TeenPregnancy/index.htm.
Ham, P., & Allen, C. (2012). Adolescent health screening and counseling. American Family Physician, 86(12), 1109-1116.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Thompson, S. (2010). The complexities of supporting teenagers in pregnancy. British Journal Of Midwifery, 18(6), 368-372.
Week 1: Building a Comprehensive Health History
According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in the United States. One of the most admired nursing skills is the ability to put patients at ease. When patients enter into a healthcare setting, they are often apprehensive about sharing personal health information. Caring nurses can alleviate the hesitance of patients and encourage them to be forthcoming with this information.
The initial health history interview can be an excellent opportunity to develop supportive relationships between patients and nurses. Nurses may employ a variety of communication skills and interview techniques to foster strong bonds with patients and to effectively facilitate the diagnostic process. In conducting interviews, advanced practice nurses must also take into account a range of patient-specific factors that may impact the questions they ask, how they ask those questions, and their complete assessment of the patient’s health.
This week, you will consider how social determinants of health such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how social determinants of health influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.
- Analyze communication techniques used to obtain patients’ health histories based upon social determinants of health
- Analyze health-related risk
- Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
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”
This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.
- Chapter 5, “Recording Information”
This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)
Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … 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, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x
Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support 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 a particular new patient assigned by your Instructor.
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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
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?
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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. NURS 6512 Building a Comprehensive Health History Paper
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.
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