Building A Health History Discussion

Running head: BUILDING A HEALTH HISTORY 1

BUILDING A HEALTH HISTORY 2

Respond to THE TWO POST BELOW SEPARATELY two of your colleagues 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.

POST 1

Denise Moon

Posted Date:

June 3, 2021 12:59 AM

Status:

Published

WK1+Moon, Denise (1st Discussion Board)

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

Upon meeting the patient for the first time, the APRN should introduce themselves to the patient and address him by his last name, ex Mr. Brown, and repeat his name when addressing him throughout the appointment. The APRN must sit close to the patient, not behind a desk or table, and look at the patient while talking with him, not looking at an electronic device or typing. The APRN may ask the patient if he minds if they take brief notes while conducting the assessment. The APRN should begin by asking the patient what bought them into the office. “Listen and do not be too directive; you will often be surprised at how much of the story and details you will hear without pushing. Let the patient share his full story and reason for seeking care.” (Ball, J.W. et al)

The APRN will build a health history through the patient to discover issues and problems related to the office visit. The chief concern is written as a brief statement, proceed by past medical history (PMH). PMH is a baseline for assessing present concerns such as severe injuries and resulting disabilities, obtain complete details if present problems have the potential medical relation to injury and limitation of ability to function because of past events.” (Ball, J.W. et al.) The APRN will inquire about medications, past, current, and recent medications, including dosage of prescriptions, over the counter medications.

A family Health History is obtained for the Health Risk Assessment, “HRA is to evaluate an individual’s risk for developing common chronic diseases, allowing clinicians to develop personalized care plans, tailoring preventative care screening and testing to each action with potential risk.” (Wu, R.P. & Orlando, L.A.) Disease processes such as Diabetes Mellitus Type II, stroke, and Coronary Artery Disease may result in disabilities; therefore, a family health history must be obtained. FHH is the strongest or only predictor of disease risk. (W.U., P.R. & Orlando, L.A.)

The APRN must review the patient body systems, inquire about pain, onset, duration, and location, assess lungs, heart, lymph nodes, mouth, eyes, and ears. Inquire if the patient has noted any hearing or vision loss. Obtain a blood pressure & pulse and inquire about the G.I. system, including appetite and elimination patterns. And diet, exercise, and drug and alcohol use. “An unhealthy diet, sedentary lifestyle, smoking, and excessive alcohol consumption are the most important behavioral risk factors and are responsible for approximately 80% of cases of CHD and cerebrovascular disease.” (Jardim, T.V. et al.)

The APRN should inquire about 1.) the home conditions such as housing economic conditions, types of furnishings, pets, and their health. 2.) Occupation: descriptions of everyday work if different, access to care: 3.) transportation and other resources available to the patient type of health insurance coverage (if any). 4.) Social needs such as insurance/medication coverage, 5.) food insecurity, housing stability, employment assistance needs.

Once the APRN has completed the History and Physical examination, they can formulate a care plan and document the findings in a Problem-Oriented Medical Record. “A PORM is a commonly used process to organize patient data gained during the history and physical examination. After the history and physical examination have complied, the POMR provides a format for collecting and recording your thoughts that assist with critical thinking and clinical decision making-determining the patients’ problems as well as possible and probable diagnoses.” (Ball, J.W.)

References

Ball, J.W., Dins, 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. Ch 1 pp 7, 13, 61.

Jardim, T.V. et al. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1-7. https://doi-org,ezp.waldenulibrary.org/10.1186/s12889-015-2477-8.

Wu, R.R., & Orlando, L.A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508-513.

Desiree Smith

POST 2

Patient Profile: 16-year-old white pregnant female living in an inner-city neighborhood

Building a Health History

For an effective relationship to begin, the physician [APN] must like teenagers, be comfortable interacting with them, respect them as individuals, and be willing to relate to them in a non-judgmental manner without being nondirective (Barnes.1990). During my interview with Kathy, I first established trust and rapport while also establishing boundaries in regard to patient confidentiality. I informed the patient that while there are things that I will not discuss with her parents; sexual abuse, illicit drug use, suicidal ideations (to name a few) are things that I must disclose.

Interview and Communication Techniques

Asking the patient adult quality questions while ensuring that it is asked in a way for her to understand is an effective way of communicating with the teen patient. As an APN, I would refrain from using the latest “slang” or teen jargon in order to maintain professional boundaries. Understanding that this experience may be frightening and embarrassing, I would allow the patient to discuss how she felt and what were her hopes, fears etc about being a teen mom while informing her of other options so that she could make an informed decision. Maintaining eye contact and asking open-ended questions is another way to derive a more informed health history from the teen.

Risk Assessment Instrument

The Risk Assessment Instrument most beneficial with this patient would be her ability to care for the child as well as her own emotional and mental state of becoming a teen mother. Living in an inner-city community where crime may be high and resources are often low, I would assess if the mother and family had access to public transportation, grocery store etc. I would also inquire about neighborhood safety.

5 targeted Questions

The 5 targeted questions that I would ask would be “Tell me how you feel about being a teen mom”, “How many sexual partners have you had and do you know who fathered your child”, “Is there a chance that you may have a sexually transmitted disease”, “Who is going to help you support the child” and “Tell me of your living arrangements”.

Reference

Barnes, HV (1990) The History, Physical, and Laboratory Examinations. 3rd edition: The Adolescent Patient, page 223 Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK708/

Running head: BUILDING A HEALTH HISTORY

1

Respond

to

THE TWO POST BELOW SEPARATELY

two

of your

colleagues

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.

POST 1

Denise

Moo

n

Posted Date:

June 3, 2021 12:59 AM

Status:

Published

WK1+Moon,

Denise

(

1

st

Discussion

Board

)

A

76

–

year

–

old

black

male

with

disabilities

living

in

an

urban

setting

.

Upon

meeting

the

patient

for

the

first

time,

the

APRN

should

introduce

themselves

to

the

patient

and

address

him

by

his

last

name,

ex

Mr.

Brown,

and

repeat

his

name

when

addressing

him

throughout

the

appointment.

The

APRN

must

sit

close

to

the

patient,

not

behind

a

desk

or

table,

and

look

at

the

patient

while

talking

with

him,

not

looking

at

an

electronic

device

or

typing.

The

APRN

may

ask

the

patient

if

he

minds

if

they

take

brief

notes

while

conducting

the

assessment.

The

APRN

should

begin

by

asking

the

p

atient

what

bought

them

into

the

office.

“Listen

and

do

not

be

too

directive;

you

will

often

be

surprised

at

how

much

of

the

story

and

details

you

will

hear

without

pushing.

Let

the

patient

share

his

full

story

and

reason

for

seeking

care.”

(Ball,

J.W.

et

al

)

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