NURS 6512N Discussion: Building a Health History

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NURS 6512N Discussion: Building a Health History

Building a Health History

Case Study B: 14-year-old biracial male living with his grandmother in a high-density public housing complex

When establishing an initial relationship with a new patient, it is wise to build a history based on an involved joint effort that genuinely reflects the unique perspectives of the individual being interviewed (Ball et al., 2019).   The key to establishing a positive patient relationship lies in the 4 C’s of effective communication: courtesy, comfort, connection, and confirmation (Ball et al., 2019). Throughout this discussion, I will address some effective communication and interview techniques used specialized for the patient in the case study and recommend an appropriate assessment tool and develop five questions targeted for this specific patient.

Effective Communication and Interview Techniques

The basis for effective communication begins with trust.  Establishing a trusting relationship occurs through being courteous, providing emotional and physical comfort, an honest connection, and confirming that the patients’ concerns are understood.  Again, these are the 4 C’s of effective communication.  It is also important to remember that every patient is unique, and the initial interview should be tailored to the individual. NURS 6512N Discussion: Building a Health History

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The patient in the case study is a 14-year-old male, which creates some unique challenges to identify during the initial interview.  Obtaining consistent, continuous, and corroborative information and adolescent and family often poses a significant challenge (Srinath et al., 2019).   Adolescence is defined as the second decade of a child’s life and includes the physical, hormonal, and psychosocial changes that come with puberty.  Adolescents are particularly vulnerable during this period due to bodily changes, peer pressure, and self-identity establishment (Smith & McGuinness, 2017).  Children in this stage are also prone to risk-taking behaviors, including experimenting with smoking, drugs, alcohol, and sexual activity, which can have life-changing consequences.

Confidentiality is the most critical concept when addressing an adolescent.  It is crucial to introduce yourself and state your title to the patient when initiating the interview.  Especially when there may be a parent or family member present, adolescents may be reluctant to speak, which is where trust and confidentiality factor in.  In this case, a 14-year-old may or may not be comfortable discussing personal details in front of his grandmother.  In which case, she may be asked to step out and the interview conducted in private.  Situations need to be evaluated case by case.

The initial interview should be conducted in a welcoming environment with minimal distractions between the patient and the provider conducting the interview.  Discussions about the patients’ day-to-day experiences and open-ended conversations about home, school, activities, and friends prove beneficial (Ball et al., 2019).  Forcing the conversation with an adolescent can lead to confrontation, which adolescents do not handle well, thus jeopardizing any trust established. NURS 6512N Discussion: Building a Health History

Risk Assessment Tool

The screening tool I would use to determine and evaluate the risks for this patient is the HEEADSSS examination.  Given that our patient is of middle adolescence and a male, he is at a substantially increased risk of risk-taking behaviors.  Furthermore, his current living situation presents an additional threat to the patient’s well-being.  The HEEADSSS examination addresses the home environment, education, eating, activities, drugs/alcohol, sexuality, suicidality, and safety and is a valuable tool for assessing the physical, emotional, and social well-being of adolescents (Smith & McGuiness, 2017).

Targeted Questions

  1.  Can you tell me about your living situation and how things are going at home?
  2. How is it going at school? Is there any subject that you are doing great in/ or struggling with?
  3. Are you in a relationship? And if so, how is it going? Are you sexually active?
  4. What kind of activities do you like to do with your friends?
  5. Have you experimented with smoking? Drugs? Or Alcohol?
  6. Have you witnessed or been a victim of violence?

References

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

Sharma, E., Srinath, S., Jacob, P., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian Journal of Psychiatry, 61(8), 158. https://doi.org/10.4103/psychiatry.indianjpsychiatry_580_18

Smith, G. L., & McGuinness, T. M. (2017). Adolescent psychosocial assessment: The HEEADSSS. Journal of Psychosocial Nursing and Mental Health Services, 55(5), 24-27. https://doi.org/10.3928/02793695-20170420-03

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. NURS 6512N 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.

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.

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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

NURS_6512_Week_1_Discussion_Rubric

Excellent Good Fair Poor
Main Posting
Points Range: 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. NURS 6512N Discussion: Building a Health History
Points Range: 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.
Points Range: 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.
Points Range: 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
Points Range: 10 (10%) – 10 (10%)
Posts main post by Day 3.
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response
Points Range: 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.
Points Range: 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.
Points Range: 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.
Points Range: 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
Points Range: 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.
Points Range: 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.
Points Range: 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.
Points Range: 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
Points Range: 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on three different days.
Total Points: 100