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NURS 6512 Building a Health History

NURS 6512 Building a Health History

The assigned case study is of an 85-year-old white woman living alone with no family and declining health. When interviewing the patient, I would ask her reason for visiting the clinic. I would inquire further about the chief complaint by asking about the onset, location, duration, characteristics, associated symptoms, alleviating/relieving factors, and severity (Graham et al., 2023). Since this is a geriatric patient, I would ask her about her medical history, taking note of chronic illnesses, past and current medications, and response to the various treatments (Graham et al., 2023). The interview would also focus on the patient’s social history, particularly her living status, how she copes with living alone, and whether she has friends or a social support system. I will also ask her about her diet, including where she sources food from and the type of foods she eats. I would also inquire on whether she has been abused physically, emotionally, sexually, or financially.

The communication techniques I would employ when interviewing this patient include using open-ended, non-structured questions. This is important in allowing the patient to express her concerns without limitations and create more questions from her response. Another technique will be to carefully phrase questions, which will help get more accurate responses from the patient. Based on the patient’s age, I would ask one question at a time and refrain from bombarding the patient with multiple questions, which can discourage her from responding appropriately (Ball et al., 2021). Besides,

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I would ask questions using simple and plain language and refrain from using medical jargon to ensure the patient fully understands and responds appropriately (Jack et al., 2022)

The selected screening tool for this patient is the Geriatric Depression Scale (GDS). GDS is a self-report tool for depression in geriatrics and uses a “Yes/No” response format (Krishnamoorthy et al., 2020). The patient is at risk of depression, considering her deteriorating health and living alone. Thus, GDS can be used to assess signs of depression and guide in taking the necessary early interventions.

Five targeted questions

  1. How would you describe your overall quality of life?
  2. What problems do you experience when carrying out activities of daily living?
  3. What challenges do you face in accessing healthcare?
  4. How has your mood changed in the past couple of weeks?
  5. Do you ever feel hopeless about life and wish that all can end?

References

Ball, J. W., Dains, 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.

Graham, B., Smith, J. E., Nelmes, P., Squire, R., & Latour, J. M. (2023). Initial Development of a Patient Reported Experience Measure for Older Adults Attending the Emergency Department: Part I-Interviews with Service Users. Healthcare (Basel, Switzerland), 11(5), 717. https://doi.org/10.3390/healthcare11050717

Jack, K., Ridley, C., & Turner, S. (2022). Effective communication with older people. Nursing older people, 34(3). doi: 10.7748/nop.2019.e1126

Krishnamoorthy, Y., Rajaa, S., & Rehman, T. (2020). Diagnostic accuracy of various forms of geriatric depression scale for screening of depression among older adults: Systematic review and meta-analysis. Archives of Gerontology and Geriatrics, p. 87, 104002. https://doi.org/10.1016/j.archger.2019.104002

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Building a Health History

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.

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

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
    • Chapter 2, “The History and Interviewing Proce
      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 5, “Recording Information”
      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 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Required Media

Welcome and General Course Guidelines
Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

 

Module 1 Introduction
Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

 

Building a Comprehensive Health History – Week 1 (19m)

 

Optional Resources

  • LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.
    • Chapter 2, “History Taking and the Medical Record” (pp. 14–27)

To prepare:

With the information presented in Chapter 2 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 2 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 Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!   

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

NURS_6512_Week_1_Discussion_Rubric

NURS_6512_Week_1_Discussion_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome Main Posting
50 to >44.0 ptsExcellent

“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.

 44 to >39.0 ptsGood

“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.

 39 to >34.0 ptsFair

“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.

 34 to >0 ptsPoor

“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.
50 pts
This criterion is linked to a Learning Outcome Main Post: Timeliness
10 to >0.0 ptsExcellent

Posts main post by Day 3.

 0 ptsFair

N/A

 0 ptsGood

N/A

 0 ptsPoor

Does not post main post by Day 3.
10 pts
This criterion is linked to a Learning Outcome First Response
18 to >16.0 ptsExcellent

“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.

 16 to >14.0 ptsGood

“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.

 14 to >12.0 ptsFair

“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.

 12 to >0 ptsPoor

“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.
18 pts
This criterion is linked to a Learning Outcome Second Response
17 to >15.0 ptsExcellent

“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.

 15 to >13.0 ptsGood

“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.

 13 to >11.0 ptsFair

“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.

 11 to >0 ptsPoor

“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.
17 pts
This criterion is linked to a Learning Outcome Participation
5 to >0.0 ptsExcellent

Meets requirements for participation by posting on three different days.

 0 ptsFair

N/A

 0 ptsGood

N/A

 0 ptsPoor

Does not meet requirements for participation by posting on three different days.
5 pts
Total Points: 100

 











		


		
		
		
		
	


	
		
			


	


	









	

		

											
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