Discussion: building a health history

The Profile

4-year-old biracial male living with his grandmother in a high-density public housing complex.

Discussion

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.

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.

Discussion one UK

I was opportune to interview a 62 yr old African American woman who came in with several health concerns. As stated by Ball et al., (2019), I located a comfortable and secure space to converse with the patient. I introduced myself and maintained eye contact with the patient as I observed her mannerisms (pp. 1). I began to inquire on what brought her in, which she stated the chief complaint of high blood cholesterol and some co-morbid concerns like obesity, hypertension, and arthritis. We did explore her family background and she revealed that obesity, hypertension, and high blood cholesterol runs in the family. Other areas that were explored were her social history, which she stated is nonexistent as well as personal and medical history. I had inquired what her diet and activity levels were. She responded that due to her limited income, she could barely afford to purchase fresh and healthier foods over processed foods and her lifestyle was mostly sedentary. She did state she has been overweight most of her life and has gotten worse as she grew older.

Regarding communication techniques available for use, I choose to build her history by utilizing open-ended questions, building rapport, active listening, and empathy to create the medium for us to have some revealing and useful pieces of information. 

  I decided to use the following techniques because 

  • Open-ended questions require more than a yes or no answer, but explanations to answer a question.
     
  • Building rapport is foundational to enabling that the patient feels comfortable opening-up
     
  • Active listening ensures that I am hearing the patient rather than assume on what the patient is saying
     
  • Empathy according to Merriam Webster is my capacity to be sensitive, relate or understand the patient’s situation. 
     

The risk assessments I employed for the stated patients were:

Fall risk assessment

Stroke risk assessment

Psychosocial risk assessment

Psychological risk assessment

Nutritional risk assessment

  These risk assessments are justifiable for this patient’s reasons based on her age, demographics, limited income, gender, little to no education, poor health status, and lack of a dependable support system. 

The five targeted questions I would ask the patient are as follows:

  1. What are your expectations for today’s visit?
     
  2. How would describe your emotional wellness on a good day compared to a bad day?
     
  3. What are the things you want to change about your health status?
     
  4. Can you support yourself or do you have people that can offer dependable support?
     
  5. Are you willing to work with the different caregivers to help improve and manage your health? (Nursing Researchers, 2020, p. 5)
     

In Conclusion, I believe as time progresses, the relationship will continue to grow and become more trusted, creating the avenue for more information to be shared by the patient that can help the nurse practitioner in conjunction with other professionals develop a plan of care that can positively improve the patients general well being.

References

Ball, J., Dains, J. E., A, J., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s physical examination handbook : an interprofessional approach. Elsevier.

Definition of EMPATHY. (2009). Merriam-Webster.com. https://www.merriam-webster.com/dictionary/empathy

Nursing Researchers (2020). Risk assessment Instruments. https://www.nursingresearchers.com/risk-assessement-instruments/

Discussion 2 Drag 

A 76-year-old black male with disabilities living in an urban setting.

            The interview for the 76-year-old black male with disabilities living in an urban setting should take place in a place where the patient should feel comfortable, in a setting where it doesn’t interfere with the disabilities mentioned. First and foremost, I will find a quiet and well-lit place to conduct the interview. During the assessment process, I will be mindful of the sensory deficit since some older adults have sensory losses, such as hearing, which makes communication more difficult. So, I will position myself in front of the patient, and speak as clearly as I can, slowly, to fully engage and gain as much information from the patient. I also come prepared to use other tools such as writing material to conduct the interview – if the patient requires/prefers to interview in writing (Ball et al. 2019).

            Assuming the interview will take place in a hospital or clinic setting, I will first knock on the door, introduce myself, perform hand hygiene, and explain the reason why I am in the room. Once the patient acknowledged and agree to participate in the interview, I will ask the patient what he/she needs to help with the interview – considering the disability factor mentioned, I would ask if the patient needs an interpreter (sign language), visual or hearing aid, and find out if the patient’s disability can hinder the interview.

            During the interview, I will be mindful to ask open-ended questions. Open-ended questions are used alone or in combination with other interviewing techniques to explore topics in-depth, to understand processes, and to identify potential causes of observed correlations (Weller et al., 2018). This may allow the patient to engage and express his thought freely and answer the questions in a detail-oriented manner. Like any other interview, I will refrain from interjecting my personal views, being judgmental, and maintain make eye contact during the interaction. I will give the patient ample time to respond and take as much time as needed to recall information.

            For the initial assessment, I will use the HEEADSSS screening tools to assess the patient’s home environment, education, or if employed, eating habits and capabilities, activities, use of drugs or medications, sexuality, suicide or ongoing depression, and safety or injury concerns (Ball et al. 2019). With that in mind, the first thing I would do is endeavor the limitation patient has or had experienced due to the disabilities and evaluate if it interferes with the basic activities of daily living, and define if the limitation is acute or chronic (Ball et al. 2019). After a complete physical assessment and medical history, I would get as much information about past and acute medical history, living arrangement, nutritional intake, medication regimen (when last medication was taken), and substance abuse issues from the patient, medical record, or family/caregiver – depending on the mental status of the patient.

Targeted questions to assess the patient’s health risks and begin building a health history.

I will target my questions for building a health history based on the patient’s social determinants, things that can impact the health of a 76-year-old black male with disabilities who are living in an urban setting. When performing a functional assessment, I will pay close attention to a variety of disabilities: physical, cognitive, psychological, social, and sexual (Ball et al. 2019). Further, mobility, activities of daily living, instrumental activities of daily living, addiction, and mental health will be the 6 targeted questions I would ask to assess the patient’s health risks and begin building a health history. Given the age of the patient, part of my assessment will emphasize on age-related risk factors: fall assessment, depression, ADL, identify what the disabilities are and assess if it interferes with the patient’s ability and competency to Make Medical Decisions and identify age-appropriate resources that are available for the patient.

Risk factors

            Fractures due to the fragility of the bone around the hip joint have become a major public health issue, presenting with an increasing incidence due to the growth of the elderly population (Alexiou et al. 2018). According to (Cimilli Ozturk et al., 2017) one-third of individuals over 65 years fall at least once a year and it has been shown that this ratio reached 50% over 80 years. Injuries due to falls in the elderly generally result in minor soft tissue probably due to the low energy of the exposed trauma. Therefore I find it imperative I ask about both recent and past history of fall and dig deep about the reason. In addition, my assessment will include both the instrumental and activities of daily living – this will include malnutrition, the ability to groom/bath, transferring from bed or chair, wheelchair, or to stand, and how much help he/she requires. In this section, I will also assess financial implications, medication management (including polypharmacy), housing, and other support systems (Ball et al. 2019).

            According to (Chhatre, et al. 2017), substance abuse among older adults is one of the fastest-growing health problems in the US. The changing demographic composition of the older adult population in the US affects not only the prevalence of substance abuse but also the need for a variety of services, including treatment. Chhatre, et al. (2017) also further explained how being African American or Hispanic was one of the several factors associated with sub-threshold alcohol dependence in the past year, and African Americans aged 55 and older were reported to have higher prevalence as well as higher rates of treatment admissions for illicit drugs such as cocaine – which puts the patient in the category mentioned.

            In addition to mental health issues, which require psychological intervention, in time of physical injury and limited mobilization, the elderly also suffer the psychosocial factors and symptoms of depression and could increase the severity of pain and the emotional distress of the patients (Alexiou et al. 2018). In this section, I will assess if the issue of polypharmacy related to pain or other functional issues.

Targeted questions

The targeted questions are the following:

  1. What is your living arrangement?
    1. Do you live alone with others?
  2. Do you have difficulty achieving your daily goals?
    1. Do you need assistance feeding?
    2. Do you need assistance walking and transferring?
    3. Do you need assistance bathing and dressing?
  3. Have you fallen recently?
    1. If yes, when, how, and ask if the patient received any medical intervention.
  4. Are you taking any medication now?
    1. How do you pay for your medication and other expenses?
    2. Do you have a support system assisting you both financially and logistically (transport) for shopping, doctor’s appointments, etc…?
  5. Do you currently drink alcohol, use illegal or controlled substances?
    1. If yes, how long and what types?
    2. When was the last time you used?
    3. Is it affecting your daily life?
    4. Do you use any medication to control pain? (address polypharmacy in this section).
  6. Have you been diagnosed with mental illness?
    1. If yes, when and what was the diagnosis?
    2. When was the last time you were admitted or have seen your provider?
    3. Are you taking any medication at the moment?
    4. Are you feeling depressed, suicidal, or homicidal?
    5. How’s your mood?
    6. Do you see or hear things?

References

Alexiou, K. I., Roushias, A., Varitimidis, S. E., & Malizos, K. N. (2018). Quality of life and psychological consequences in elderly patients after a hip fracture: a review. Clinical interventions in aging13, 143–150. https://doi.org/10.2147/CIA.S150067

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

Chhatre, S., Cook, R., Mallik, E., & Jayadevappa, R. (2017). Trends in substance use admissions among older adults. BMC Health Services Research, 17(1). doi:10.1186/s12913-017-2538-z

Cimilli Ozturk, T., Ak, R., Unal Akoglu, E., Onur, O., Eroglu, S., & Saritemur, M. (2017). Factors associated with MULTIPLE Falls among elderly patients admitted to emergency department. International Journal of Gerontology, 11(2), 85-89. doi:10.1016/j.ijge.2016.05.009

Weller, S. C., Vickers, B., Bernard, H. R., Blackburn, A. M., Borgatti, S., Gravlee, C. C., & Johnson, J. C. (2018). Open-ended interview questions and saturation. PLOS ONE, 13(6). doi:10.1371/journal.pone.0198606

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