Building a Health History

Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patients 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:

o How would your communication and interview techniques for building a health history differ with each patient?

o How might you target your questions for building a health history based on the patients age, gender, ethnicity, or environment?

o What risk assessment instruments would be appropriate to use with each patient?

o 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 patients 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 course 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.

Post on or before Day 3 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.

Readings/Recommended References (you may choose your own textbook or article for this paper)

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

o Chapter 1, Partnership with Patients: Building a History (pp. 131)

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.

o Chapter 26, Recording Information (pp. 792813)

This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowins diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

o Chapter 2, History Taking and the Medical Record (pp. 1533)

In this chapter, the authors explain the importance of medical records and of taking health histories. The chapter outlines the components of a medical record, and it provides procedures for taking health history and completing a medical record.

Deeks, A., Lombard, C., Michelmore, J., & Teede, H. (2009). The effects of gender and age on health related behaviors. BMC Public Health, 9, 213220.

Retrieved from the Walden Library databases.

This article describes a study that sought to determine the effects of gender and age on health-related behaviors. In the study, the authors also investigated the effects of screening practices, health beliefs, and perceived future health needs.

Delpierre, C., Lauwers-Cances, V., Datta, G. D., Berkman, L., & Lang, T. (2009). Impact of social position on the effect of cardiovascular risk factors on self-rated health. American Journal of Public Health, 99(7), 12781284.

Retrieved from the Walden Library databases.

This study assessed the influence of education level on the association between self-rated health and cardiovascular risk factors. The authors explain their methods and results, and they provide recommendations for similar studies in different countries and cultures.

Lee, D. W., Neumann, P. J., & Rizzo, J. A. (2010). Understanding the medical and nonmedical value of diagnostic testing. Value in Health, 13(2), 310314.

Retrieved from the Walden Library databases.

The authors of this article detail their attempts to develop a framework for defining the potential value of diagnostic testing. The authors also discuss the implications of their framework for health care delivery systems.

University of Michigan Medical School. (2003). Geriatric functional assessment.

Retrieved from http://www.med.umich.edu/lrc/coursepages/m1/HGD/GeriatricFunctionalAssess.pdf

This article provides an exercise that emphasizes accurate functional status assessments and effective communication with older patients. The authors recommend tools and techniques to be used when caring for older patients.

Building a Health History

In building a health history, effective communication is essential. Different factors such as age, ethnicity, gender, and environmental setting influence the health of a person. Nurses must understand these factors to tailor their communication techniques accordingly to establish rapport with their patients and be able to collect vital information. This paper deliberates on various aspects relating to building health history of a patient.

 The health history selected is for a 76-year-old Black/African-American male with disabilities living in an urban setting and the potential health related risks is based upon the patient age and is depression. Some of the health conditions are related to the age of an individual. Some of these health problems include falls, and chronic diseases such as stroke among others.

 In building the history, various strategies are used. One of them is interview. The interview will be one-on-one and questions asked will be open-ended. This is to ensure that the patient provides more information about his experiences and his feelings (University of Michigan Medical School, 2003). The pace of answering questions may be slow and therefore, it is important to ensure that most relevant questions come first. It is also important to establish a rapport between the physician and the patient to avoid concealing of vital information by the patient (Deeks, Lombard, Michelmore & Teede, 2009). Communication must be clear and precise. The setting or the environments in which the interview will take place too need consideration. Most elderly people have hearing problems and this will as well considered to enhance our conversation. Extraneous noise needs elimination. I will speak slowly in an even tone, will give enough time for the patient to respond to questions, and will sit facing each other at an eye level (LeBlond, Brown & DeGowin, 2009). As noted earlier, the main reason for employing these techniques is to ensure that the patient provides enough information about his health status to be able to administer better diagnosis. It makes the patient feel relaxed and free to share whatever information he has.

The risk assessments instrument that suite this patient is Geriatric Depression Scale (GDS). The 15-item questionnaire is completed either during an interview or in writing. It helps to capture various aspects or issues that affect the patient (University of Michigan Medical School, 2003). The reason why it is a suitable assessment tool for this particular patient is that it is very effective and feasible to high-risk patients as it involves writing and interviewing. It provided vital information concerning the patient health status and more specifically the level of depression. Old people are at high risk of suffering from depression because of  various challenges such disabilities as experienced  by this old man and other reasons such as seclusion from the society, among many others.

   To be able to understand the health conditions, it requires that questions asked. Some of the questions that will be posed to this patient are:

  1. During the last two months, have you often been bothered by feeling low, depressed or hopeless?
  2. Have you be bothered by little interest or pleasure in doing something?
  3. What is it that makes you feel like you do not want to live another minute?
  4. Do you find life enjoyable and fulfilling?
  5. Do you have or experience sleep problems, poor appetite, and lack of energy sometimes
  6. What is your greatest worry?

 The questions should be precise to ensure that the patient understand them and responds to them appropriately. These questions will help understand how the patient feels and will add value to the health history of the patient.

 Therefore, it is prudent that practice nurses develop good interviewing and communication skills especially when it comes to building the health history of patient. This information is critical and should be sort with due diligent as it contributes to better and quality health care. It is also important to understand various health risks and the kind of patients to use appropriate techniques in communication. In this case, dealing with an African American living in urban center and aged 70 years requires one to understand the values of the person and the likely health risks to be able to engage them in a better manner.

References

University of Michigan Medical School. (2003). Geriatric functional assessment.

Deeks, A., Lombard, C., Michelmore, J., & Teede, H. (2009). The effects of gender and age on health related behaviors. BMC Public Health, 9, 213–220.

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

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