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

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

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

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)

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.

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