Discussion: Building a Health History NURS 6512N

April 5, 2022
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NURS 6512 Week 1: Building a Comprehensive Health History

Discussion: Building a Health History NURS 6512N

Discussion: Building a Health History NURS 6512N

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.

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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.

Learning Objectives

Students will:

  • 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

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

  • Chapter 1, “The History and Interviewing Process”

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)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Optional Resource

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)
Required Media (click to expand/reduce)

Welcome and General Course Guidelines
Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

 

Module 1 Introduction
Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

 

Discussion: Building a Health History

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.

Photo Credit: Sam Edwards / Caiaimage / Getty Images

To prepare:

With the information presented in Chapter 1 of Ball et al. in mind, consider the following:

  • By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
  • How would your communication and interview techniques for building a health history differ with each patient?
  • How might you target your questions for building a health history based on the patient’s social determinants of health?
  • What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
  • Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
  • Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
  • Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
By Day 3 of Week 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6 of Week 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

  • Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
  • Suggest additional health-related risks that might be considered.
  • Validate an idea with your own experience and additional research.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 1 Discussion Rubric

Post by Day 3 of Week 1 and Respond by Day 6 of Week 1

To Participate in this Discussion:

Week 1 Discussion


What’s Coming Up in Module 2?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

In Module 2, you explore the impact of functional assessments, diversity, and sensitivity in conducting health assessments. You also examine various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.

Next week, you will specifically examine functional assessments as they relate to diversity and sensitivity

Registration for Shadow Health

Throughout this course, you will participate in digital clinical experiences using the online simulation tool Shadow Health. The Shadow Health digital clinical experience provides a dynamic, immersive experience designed to improve nursing skills and clinical reasoning through the examination of digital standardized patients. Using Shadow Health you will participate in health histories, focused exams, and a comprehensive assessment.

There will be four Shadow Health assessment components that you will need to complete in Module’s 2 and 3:

  • Health History Assessment (Week 3 & 4)
  • Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
  • Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest pain
  • Comprehensive (Head-to-Toe) Physical Assessment (Week 9)

Before you can participate in these simulations, you will need to register for a Shadow Health account. To do this:

  • Go to the Walden Bookstore and purchase access to Shadow Health and the required texts.
  • Once Shadow Health has been purchased, an access code will be emailed to you from the bookstore.
  • Review this video explaining how to register in Shadow Health: https://vimeo.com/275921826/c12d50ee6e
  • Use the Shadow Health link located in the navigation menu on the left in the Blackboard course.
  • Follow the prompts to register in Shadow Health. You will need the access code provided from the bookstore to register. Once registered, Shadow Health should always be accessed via the link in Blackboard.
  • Use only Google Chrome when accessing Shadow Health and make sure all other programs are turned off on your computer. Other browsers do not work well and will not allow the Shadow Health speech to text function to work.
  •  Once registered, complete the Shadow Health Orientation in the Shadow Health website/program and review the videos designed to assist with navigating and completing assignments.
  • Read the Shadow Health Nursing Documentation Tutorial located in the Week 1 Learning Resources.

Note: As nurses you typically use the word assessment to mean completing the physical exam. However, in the SOAP Note format, assessment means diagnosis so start getting in the habit of calling the physical exam exactly that.

Week 2 Case Studies

In Week 2, your Instructor will assign you a case study related to your Discussion by Day 1 of the week. Please make sure to review the “Course Announcements” area of the course to verify your assigned case study. Please plan ahead to ensure you have time to review your case study and your Learning Resources so that you can complete your Discussions and Assignments on time.

Photo Credit: Getty Images/iStockphoto

Next Module

 

To go to th

Discussion: Building a health history

Initial Post

A 40-year-old black recent immigrant from Africa without health insurance

Summary of the interview

As I enter the room, I greet the patient and introduce myself. I will address the patient by using his surname and shake hands if he seems comfortable. I will tell the patient the reason for the interview. For example I will ask him, “Mr. Jones, I want to ask you some questions about your medical history and concerns that brings you to the hospital.” After the brief introduction, I ask him some open-ended questions such as “what brings you to the hospital?” and tell me more how have you been feeling since your last appointment?” I ask him specific and direct questions such as “where is the pain?” “How long you have been in pain?” I ask direst questions to  patient bout the medical history, surgical history, medications, immunization history, daily habits such as drinking, smoking or taking any drugs or narcotics. I also do screening for sexual abuse, suicidal thoughts and PTSD. At the end of the interview, I ask him “if there are any questions he would like to ask?”. I gave him what he will expect next and explain about the following physical examination or any medical procedure he has to go through. I also explain the patient about the plan of action and in the end thank them for the time spent and for their cooperation. As the patient have no health insurance, patient will be anxious about the medical bill, so it is beneficial to give information regarding payment options and resources that will help him to pay medical bills. This will ease the patient anxiety and open up regarding his health problems and needs. Another consideration for this patient is that the interviewer has to be aware of cultural competence care. The interviewer has to understand patient views of other people may be defined by ethnic and cultural stereotypes. The interviewer has to be aware of his or her own cultural biases and preconceptions and respect patient cultural beliefs and aware of the limitations in addressing health issues across cultures. 

 

Description of the communication

 

Interview is the first and important part of data collection. The goal of the interview is to record a complete health history. Good interviewing skill can obtain all important information from the patient and also build rapport and trust for a successful working relationship. As the patient is recently immigrated from the Africa and without insurance, the interviewer has to establish a trust relationship so that the person feels accepted and free to share all relevant data. To build a trusting relationship, it is important to cultivate factors such as empathy, respect, active listening and accept unconditionally. The communication techniques for the effective interview are asking both open ended and closed or direct questions. Open ended questions encourages the person to express himself or herself. Closed ended or direct question is asked when specific information are needed and also it will speed up the interview an leaves interaction neutral.

Risk Assessment

 

Health risk assessment provide an opportunity to promote health by determining risk for chronic and rare disease conditions and emphasis health promotion and disease prevention (Wu & Orlando, 2015). Including family health history in health risk assessment helps to evaluate an individual risk for developing common chronic conditions. Family health history can make big difference in the recommended age for screening and can inform clinical decision making and preventative services (Lushniak, B., D., 2015).In this case scenario as the patient is from Africa, family history can provide more knowledge about treatment guidelines and screenings that are required for preventative services. Cultural assessment is another tool for improving patient safety. It will provide a knowledge about patient health beliefs and practices, patient diet and nutritional practices that may vary from the care giver.  Health risk assessment also helps to determine patient’s social and psychological condition and helps enhance the preventative care. Health risk assessment tools includes suicide screening, mental health assessment, violence assessment, fall risk assessment, nutritional risk assessment abuse screening. 

 

Five targeted questions

 

What brings you to the hospital?

What is your past medical and surgical history?

Do anybody in your family have hypertension, heart disease, cancer or any specific disease?

What are the medications that you are taking at home?

Do you feel like hurting yourself and killing yourself?

Did you lost significant amount of weight in recent months without trying?

 

 

 

References

 

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 (9thedition). St Louis, MO: Elsevier Mosby. 

 

Wu, R., Orlando L., A., 92015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal. 91(1079). 

 

Lushniak B., D., (2015). Surgeon general’s perspectives: Family health history: using the past to improve future health. Public Health Reports. 1(3). PubMed. 

 

e next module:

Module 2

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6512_Week_1_Discussion_Rubric
Grid View
List View
Excellent Good Fair Poor
Main Posting
45 (45%) – 50 (50%)
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
40 (40%) – 44 (44%)
“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
35 (35%) – 39 (39%)
“Responds to some of the Discussion question(s). One or 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 two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.
0 (0%) – 34 (34%)
“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. 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 Post: Timeliness
10 (10%) – 10 (10%)
Posts main post by Day 3.
0 (0%) – 0 (0%)
N/A
0 (0%) – 0 (0%)
N/A
0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response
17 (17%) – 18 (18%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
15 (15%) – 16 (16%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses 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.
13 (13%) – 14 (14%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
0 (0%) – 12 (12%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response
16 (16%) – 17 (17%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
14 (14%) – 15 (15%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses 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.
12 (12%) – 13 (13%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
0 (0%) – 11 (11%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation
5

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