NURS6512 Week 1 Discussion
NURS6512 Week 1 Discussion: Building a Health History
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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To prepare:
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
How would your communication and interview techniques for building a health history differ with each patient?
How might you target your questions for building a health history based on the patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
NURS 6512 Week 1 Discussion Example
The history should be structured to include the chief concern, history of present illness (HPI), past medical history, family history, personal and social history and review of systems (ROS) (Ball et al, 2015). With many Electronic Medical Records (EHR’s) many of these items are readily available in the system. They should be reviewed during the history taking portion of the exam.
Communication and Interviewing Techniques
To enhance patient response I would use open ended questions, direct questions and leading question (Ball et al, 2015). The patient history is important to identify potential genetic risks as well as to establish a sense of the patient’s reliability (Ball et al, 2015) NURS 6512 Week 1 Discussion example . The technique used by the clinician is almost as important as what they are asking. It is important to ask probing questions for more information, set the scene for an open dialogue, and avoid the use of jargon,
Targeted Questions
The history portion of the exam helps the practitioner to identify what targeted questions should be asked. In an article by Lushniak, B. (2015) they state that the family health history is the most cost effective genetic screening tool. They found that for all diseases of public health significance, individuals with a family history of the disease have a higher risk of developing the disease than those without a family history. NURS 6512 Week 1 Discussion example
Health risk assessments provide an opportunity to encourage health promotion and disease prevention (Wu, R. and Orlando, L.(2015). HRA’s assist in bringing guidelines and risk assessments into one tool to assist in assess the risk and recommended management of disease.
Scenario
In building a health history for a new patient who is 16 years old, pregnant and living in an inner city neighborhood. I would plan to conduct a basic health history that consists of a chief complaint, HPI, past medical history, personal and social history and ROS. The medical and family history would include targeted questions about genetic birth defects, to ensure proper prenatal testing occurs. It would be important to include health assessment tool such as the HITS screen for domestic violence, the five P’s of sexual practice and the HEADESSS (screening tool for adolescent issues.
Assessment Questions
- What brings you in to the clinic today?
- What symptoms have you been experiencing in the last month?
- Can you tell me about who lives at home with you?
- Do you feel safe in your home? At school?
- Can you tell me at what age you had your first period?
- Have you ever missed or had a late period before?
- Are you currently sexually active? NURS 6512 Week 1 Discussion example
- How many partners have you had in the past year?
- What kind of contraception do you use? Do you use it every time?
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.
Lushniak, B. D. (2015). Surgeon General’s Perspectives. Public Health Reports, 130(1), 3–5.
Wu RR, Orlando LA. (2015). Implementation of health risk assessments with family health history: barriers and benefits. Postgraduate Medical Journal;91:508-513. NURS 6512 Week 1 Discussion example
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