NRNP 6552 Taking a Health History: Building a Health History: Asking Difficult Questions

NRNP 6552 Taking a Health History: Building a Health History: Asking Difficult Questions

Taking a Health History: Building a Health History: Asking Difficult Questions

            Once the nurse starts working with a patient, one of the first things they do is look at their medical background to learn more about why they are there. The process entails gathering significant personal data from the patient, which is utilized in medical reasoning and decision-making (Casanova et al., 2023). It may require asking the patient challenging questions that necessitate efficient interpersonal abilities and the application of professional competencies. This paper illustrates a script for building a patient’s health history.

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Part 1: Script

Introduction

  • Hello, my name is ______. I am the Nurse Practitioner assigned to your care today. May I ask you a series of questions? What name would you want to be called?

General Medical History

  • Could you provide me with an overview of your medical background?
  • Have you had any surgical interventions or medical treatments in the past? If so, what kind of kind? At what time did these events take place?
  • Have you ever been admitted to a hospital? Under what circumstances, at what time, and for what reason? (DesRoches et al., 2020).

Reason for Seeking Care/ Chief Concern

  • What was the purpose of your visit to the clinic today?
  • Have you encountered this issue previously?
  • May I inquire about the specific area where the issue or discomfort is located? How long has this situation lasted?
  • Please rate the severity of the pain on a scale of 0 to 10. (Fraze et al., 2020).

Mental Health History

  • Have you ever experienced any mental health issues, either in the past or currently? Have you ever received mental health treatment in an inpatient or hospital setting? Are you currently taking any medication for mental illness? (Yang et al., 2020).

Medications and Allergies

  • Do you currently use any prescription drugs? What type, if any? What is the medication’s dosage? Why are you taking the medicine? When did you begin using these drugs?
  • Do you suffer from any food allergies, seasonal allergies, or drug allergies? (Avery et al., 2020).

Substance Use

  • Do you drink beer, do drugs, or smoke cigarettes?
  • Have you ever used prescription or over-the-counter drugs in the wrong way? How often do you use it, and what kind do you use? (Arnold et al., 2020).

Family Health History

  • Could you give me some information about your parents’, grandparents’, and brothers’ health history?
  • Does anyone in your family have a history of breast, ovarian, or cervical cancer? (Ruud et al., 2021).

Gynecological Health History

  • May I inquire about the age at which you first experienced menstruation? How recently did you have menstruation? What is the typical duration of your menstrual cycle? Do you typically experience a light or heavy flow during your menstrual cycle?
  • What is your gender identity?
  • Are you currently engaged in sexual activity? Could you please clarify the number of sexual partners you currently have? Do you prioritize practicing safe sex and taking necessary precautions? What concerns or questions do you have regarding the current status of your sexual relationship?
  • Are you currently using any form of contraception? What type, if any? How long have you been using this form of contraception? Are you experiencing any adverse effects or symptoms from the contraception?
  • What is your history of childbirth? May I inquire about the number of your surviving offspring? Could you please provide the breakdown of the delivery methods used for your pregnancies?
  • Have you ever had any previous sexually transmitted infections?
  • Are you experiencing any issues with stools or urine incontinence? Are you experiencing any issues with burning sensations, frequent urination, or a sense of urgency?
  • Have you noticed any instances of abnormal vaginal bleeding during your menstrual cycle?
  • May I inquire about the date of your most recent pap smear? What were the results of your study? Have you made arrangements for a subsequent examination following the abnormal pap smear finding? Have any additional tests been conducted? Were any tests conducted, and what were the results? (Oats & Boyle, 2022).

Conclusion:

  • Is there additional information you would want to discuss? Do you have any more questions for me?

Part 2: Reflection/Conclusion

The process of developing this screenplay was more challenging than I had anticipated. My realization that social determinants of health may play a significant influence in the medical care and treatment of a patient came about as a result of my completion of this assignment. Following a second reading of several of my inquiries, I would have rephrased them in order to improve the patient’s comprehension of them. When it comes to communicating with patients, asking them about their sexual orientation and sexual health may be a very difficult topic to discuss (DesRoches et al., 2020). The patient may experience discomfort, and it will give both. Not only does it assist us in providing the finest and most accurate treatment for our patients’ sexual health, but it also screens for risk for other disorders, such as atherosclerotic cardiovascular disease. As nurse practitioners, we need to be able to acquire an accurate and full history.

As a nurse practitioner, I believe that my community needs more accessible materials about sexually transmitted illnesses and diverse contraceptive options. For instance, the LGBTQ community is considered a vulnerable demographic because of the prejudice and discrimination they face from other individuals in society. Regular women’s health checkups for this demographic will include screening for pregnancy, fluctuations in body weight, and osteoporosis, along with breast cancer, among other conditions (Oats & Boyle, 2022). Several smartphone apps suitable for pregnancy screening comprise Sprout Pregnancy, and My Pregnancy, among others. Some applications that may be used for anxiety screening include Calm and Dare, among other options. These technologies facilitate the dissemination of readily available screening services in order to enhance the well-being and security of vulnerable people. Recent studies have shown that sex education imparts to young persons the importance of treating all individuals, including themselves, with decency and respect.

References

‌ DesRoches, C. M., Leveille, S., Bell, S. K., Dong, Z. J., Elmore, J. G., Fernandez, L., Harcourt, K., Fitzgerald, P., Payne, T. H., Stametz, R., Delbanco, T., & Walker, J. (2020). The views and experiences of clinicians sharing medical record notes with patients. JAMA Network Open, 3(3), e201753. https://doi.org/10.1001/jamanetworkopen.2020.1753

Arnold, C., Berger, S., Gronewold, N., Schwabe, D., Götsch, B., Mahler, C., & Schultz, J. (2020). Exploring early interprofessional socialization: a pilot study of student’s experiences in medical history taking. Journal of Interprofessional Care, 1–8. https://doi.org/10.1080/13561820.2019.1708872

Avery, M. D., Jennings, J. C., Germano, E., Andrighetti, T., Autry, A. M., Dau, K. Q., Krause, S. A., Montgomery, O. C., Nicholson, T. B., Perry, A., Rauk, P. N., Sankey, H. Z., & Woodland, M. B. (2020). Interprofessional education between midwifery students and obstetrics and gynecology residents: An American College of Nurse‐Midwives and American College of Obstetricians and Gynecologists collaboration. Journal of Midwifery & Women’s Health, 65(2), 257–264. https://doi.org/10.1111/jmwh.13057

Casanova, R., Geopfert, A. R., Hueppchen, N., Weiss, P. M., & Anna Marie Connolly. (2023). Beckmann and Ling’s Obstetrics and Gynecology. Lippincott Williams & Wilkins.

Fraze, T. K., Briggs, A. D., Whitcomb, E. K., Peck, K. A., & Meara, E. (2020). Role of nurse practitioners in caring for patients with complex health needs. Medical Care, 58(10), 853–860. https://doi.org/10.1097/mlr.0000000000001364

Oats, J. J. N., & Boyle, J. (2022). Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology, E-Book. Elsevier Health Sciences.

Ruud, M. N., Demma, J. M., Woll, A., Miller, J. M., Hoffman, S., & Avery, M. D. (2021). Health history skills for interprofessional learners in transgender and nonbinary populations. Journal of Midwifery & Women’s Health, 66(6), 778–786. https://doi.org/10.1111/jmwh.13278

Yang, B. K., Johantgen, M. E., Trinkoff, A. M., Idzik, S. R., Wince, J., & Tomlinson, C. (2020). State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic review. Medical Care Research and Review, 78(3), 183–196. https://doi.org/10.1177/1077558719901216

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Taking a Health History: Building a Health History: Asking Difficult Questions

Much of an archeologist’s work is done under the mantra “proceed with caution.” Archeologists must dutifully secure permissions to access sites. They also must exercise extreme caution when excavating or analyzing in a lab to avoid potential damage to historical artifacts.

Likewise, nurse practitioners must proceed with caution when building a patient’s health history. Important questions can be difficult for both nurse and patient. Care must be taken to approach such questions with dignity, tact, and respect to create an environment conducive to productive conversations.

More importantly in today’s society, the possible Social Determinants of Health for each of our patient’s also needs to be taken into consideration

For this Assignment, you will develop a make-believe script to be used when you first encounter a patient for a well woman appointment.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

  • Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
    • Chapter 6, “Gynecologic Anatomy and Physiology” (pp. 87–98)
    • Chapter 7, “Gynecologic History and Physical Examination”?(pp. 99–124)?(Previously read in Week 1)
    • Chapter 9, “Periodic Screening and Health Maintenance” (pp. 149–164)
    • Chapter 12, “Sexuality and Sexual Health” (pp. 211–228)
    • Chapter 13, “Contraception” (pp. 236–266)
    • Chapter 14, “Menopause” (pp. 267–291)
    • Chapter 15, “Intimate Partner Violence” (pp. 295–307)
    • Chapter 16, “Sexual Assault” (pp. 313–329)

Screening Guidelines

Adult Gerontology Resources

  • Links to an external site. The Journal of The North American Menopause Society , 21(10), pp. 1-25. http://www.menopause.org/docs/default-source/2014/nams-recomm-for-clinical-care.pdf

Resources for LGBTQ+

  • Links to an external site.. Women’s Health Issues , 28(4), 350–357. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.whi.2018.03.002

Apps for Common Screenings

The following common screening apps will require a download or install into your personal device for you to access. Note: Should you have any technical issues, you will need to contact the rightsholder of the app itself and not Walden Student Support for any assistance.

Note: This download is available for Android devices only.

Note: This download is available for iOS devices only.

Note: This webpage will provide you with downloads for both iOS and Android Devices.

Clinical Guideline Resources

Required Media

  • Taking a Health History
    Dr. Marianne Shaughnessy discusses one of the most critical components of the nurse/patient relationship—the health interview with the patient. She further discusses how to conduct a health history interview with demonstration (16 mins).
  • Women’s Issues and Tough Conversations
  • Links to an external site.
    In this interactive media program, Dr. Rebecca Lee and Cindy Nypaver describe their experiences related to women’s issues and tough conversations (5 mins).

Optional Resources

Note: In Weeks 1-10, these resources are optional for your review. In Week 11, you will be required to review each of the PowerPoint slides from the text Gynecologic Health Care (4th ed.).

To prepare:

  • Review the screening tools found in the Learning Resources and consider how you might use an app or tool to assist in screening.
  • Review the media programs related to a vaginal exam, pap test, and breast exam.
  • Review the health history guide presented in Chapter 7 of the Schuiling & Likis (2022) text and consider how you would create your own script for building a complete health history. (Note: You will also find the Health History Form in Chapter 7)
  • Provide all the components of a complete gynecologic health history. Include considerations for special populations such as LGBTQ+ individuals.
  • What health maintenance guidelines should be included for initial and follow up might be needed for follow-up assessments?  (i.e., bone density test, Gardasil vaccine, pap smear, Mammorgram, etc.)?
  • Using the 5 areas of the Social Determinants of Health:
    (Examples of SDOH include but not limited to)
    • Safe housing, transportation, and neighborhoods
    • Racism, discrimination, and violence
    • Education, job opportunities, and income
    • Access to nutritious foods and physical activity opportunities
    • Polluted air and water
    • Language and literacy skills
    • SDOH also contribute to wide health disparities and inequities.
    • What questions would you consider in your patient’s complete health history?
  • Develop your own script for building a complete health history and as you create your script, consider the difficult questions you want to include in your script. There is no sample template to provide to you. (Utilize chapter 7 of your Schuiling textbook to provide guidance). You are the one to develop the script. Think of it as you are writing a movie and you need to write the script for the movie. What lines would you provide for the actor to utilize when sitting down with a patient to perform a COMPLETE Medical History which also entails those DIFFICULT GYN questions. You do not need to provide the answers to the questions however, if you find that beneficial, you may do so.

Assignment: (1- to 2-page reflection)

  • In addition to your script for building a health history for this assignment, include a separate section called “Reflection” that includes the following:
    • A brief summary of your experiences in developing and implementing your script during your health history.
    • Explanations of what you might find difficult when asking these questions. What you found insightful and what would you say or do differently.
    • As a NP, what could you implement in your community to provide resources/assistance of the Social Determinants of Health.

Reminder

Links to an external site.: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.

By Day 7 of Week 2

Submit your Module 1 Assignment by Day 7 of Week 2.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as M1Assgn_LastName_Firstinitial
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6552_Module1_Assignment_Rubric

NRNP_6552_Module1_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Separate from the actual script, what are the considerations for special populations such as young women, new mothers, older women, women with disabilities, and LGBTQ+ individuals? Provide health maintenance guidelines that should be included during the initial and follow up assessments. (i.e., bone density test, pap smear, Gardasil (HPV) vaccine, shingles, etc.)? 30 to >26.7 pts Excellent The response provides clear, complete, and all appropriate special considerations. Health maintenance guidelines are clear and complete.

26.7 to >23.7 pts Good The response provides clear, complete, and most of the special considerations. Most health maintenance guidelines are included and appropriate.

23.7 to >20.7 pts Fair The response provides special considerations but are incomplete, vague or inaccurate. Health maintenance guidelines are somewhat complete or inappropriate applied.

20.7 to >0 pts Poor The response provides unclear, incomplete, or inappropriate components . The special considerations and the maintenance guidelines are missing, incorrect, or inappropriate applied.

 30 pts
This criterion is linked to a Learning Outcome Building a Health History: Asking Difficult Questions. Create your own script for building a health history. Consider the type of language you would use to help your patient be more comfortable). Ensure you include the difficult questions required to complete a thorough health history. 25 to >22.3 pts Excellent The script contains a complete set of questions, including difficult questions, necessary to build a health history. Questions are phrased in a manner that supports the patients comfort.

22.3 to >19.75 pts Good The script contains a mostly complete set of questions, including difficult questions, necessary to build a health history. Most questions are phrased in a manner that supports the patients comfort.

19.75 to >17.25 pts Fair The script containing some relevant questions, including a few difficult questions. Information collected provides a cursory health history. Questions are not phrased in a supportive tone.

17.25 to >0 pts Poor The script contains few or no relevant questions, including few or no difficult questions. Information collected is not sufficient to provide an adequate health history. Questions are not phrased in a supportive tone.

 25 pts
This criterion is linked to a Learning Outcome In addition to your script for building a health history for this assignment, include a separate section called “Reflection.” Provide a brief overview of the 5 areas of SDOH for this patient and the questions you would consider. Briefly reflect and provide a summary of your experiences in developing your script during your health history. 30 to >26.7 pts Excellent The response provides information on the SDOH and an accurate, clear, and complete summary of experiences in developing the script during the health history.

26.7 to >23.7 pts Good The response provides information on the SDOH and an accurate summary of experiences in developing the script during the health history.

23.7 to >20.7 pts Fair The response provides vague information on the SDOH and a vague, inaccurate, or incomplete summary of the experiences in developing the script during the health history.

20.7 to >0 pts Poor The response provides a vague, inaccurate, or incomplete SDOH and summary of the experiences in developing the script during the health history, or the summary is missing.

 30 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria. 5 to >4.45 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity… A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.

4.45 to >3.95 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time… Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive.

3.95 to >3.45 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time… Purpose, introduction, and conclusion of the assignment is vague or off topic.

3.45 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time… No purpose statement, introduction, or conclusion was provided.

 5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards:Correct grammar, mechanics, and proper punctuation 5 to >4.45 pts Excellent Uses correct grammar, spelling, and punctuation with no errors.

4.45 to >3.95 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.95 to >3.45 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors.

3.45 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

 5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. 5 to >4.45 pts Excellent Uses correct APA format with no errors.

4.45 to >3.95 pts Good Contains a few (1 or 2) APA format errors.

3.95 to >3.45 pts Fair Contains several (3 or 4) APA format errors.

3.45 to >0 pts Poor Contains many (≥ 5) APA format errors.

 5 pts

Total Points: 100

 

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