WK 1 ADVANCED HEALTH ASSESSMENT DISCUSSION RESPONSE QUESTION
Discussion: 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.
THE ASSIGNMENT TO BE COMPLETED
Respond to your colleague’s post below on a“26-year-old Lebanese female living in graduate-student housing” by doing 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.
• Support your work by at least four current, credible sources within the last 5yrs (2 FROM ATTACHED LEARNING RESOURCES AND 2 FROM OUTSIDE CREDIBLE RESOURCES)
First Response 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. 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. 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. 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.
COLLEAGUE’S POST BY Kristina, H
Week 1 Main Discussion
When performing a health assessment, it is essential to find an appropriate way to build a health history, to determine health issues, and determine the correct treatment needed for the individual. When a patient comes in for an evaluation for a medical concern, it is a priority for the practitioner to create a connection with the patient, how the practitioner addresses the patient may determine the amount of information that they receive back. Every interaction between a patient and their practitioner will be different because of the patient’s background, education, health beliefs, past experiences, and how they view healthcare in general. Being courteous, providing a comfortable environment and creating a connection with your patient will give a great start to the interview process (Ball, J., Dains, J., Flynn, J., Solomom, B. & Stewart, R., 2019, p. 2).
The scenario describes a 26 y.o. Lebanese female who currently resides in graduate school housing. When starting the interview, the practitioner should introduce themselves, exhibiting good eye contact, and actively listening to the patient’s concerns. One of the first things that should take precedence is to determine the ethnicity of the patient and determine her cultural needs during the interview. By assessing the personal and social history will increase understanding and patient needs. Questions could include where are you going to graduate school? Do you have family that lives close to you? What are your plans after graduating? A practitioner can determine if the patient has live in the area for a while or is just attending college or if they have a sound support system available and reliable relationships in a time of need. Taking the time to gather this information will build a positive rapport between patient and practitioner.
Health Risk assessment tools “enhanced patients’ experiences by increasing patient activation and shared decision making and incorporating patient values improving adherence to recommendation” (Wu, R. & Orlando, L., 2015). Target assessments for a 26-year-old female graduate student may include living arrangements, safety assessments, diet and exercise, stress reduction, the use of alcohol or drugs, smoking, sexual relationships, and healthy boundaries.
Target questions to be asked :
1. Do you smoke/vape? How often and how long have you used tobacco products?
2. Who do you live with friends or family? Do you feel safe with roommates?
3. How often do you drink alcohol? How often do you use illicit drugs?
4. Are you sexually active? How many partners have you had? Are you having protected sex, are you on some birth control?
5. How are you feeling? “In the two weeks, have you felt down or hopeless? Have you had little desire to do things that you enjoy” (Ball, J., Dains, J., Flynn, J., Solomom, B. & Stewart, R., 2019, p. 93).
6. What do you do when you are feeling stressed? Do you exercise regularly? How do you sleep?
By using tools like the Patient health questionnaire (PHQ-9) “has good sensitivity and specificity for identifying a major depressive disorder” (Ball, J., Dains, J., Flynn, J., Solomom, B. & Stewart, R., 2019, p. 94). For alcohol consumption, the use of a CAGE questionnaire to “help identify alcohol dependency” (Sullivan, 2019). The use of open-ended questions is essential to receiving adequate feedback form the patient. The practitioner should not assume anything without asking the patient about their health history and their health beliefs. Being proactive and assessing health risks “emphasize health promotion and disease prevention for patients and population at large” (Wu, R. & Orlando, L., 2015).
Ball, J., Dains, J., Flynn, J., Solomon, B. & Stewart, R. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St.Louis, MO: Elsevier.
Sullivan, D. (2019). Guide to Clinical Documentation. Philadelphia: F.A. Davis.
Wu, R. & Orlando, L. (2015). Implementations of health risk assessment with family health history: barriers and benefits. Postgrad Med Journal, 91, 508-513. doi:10.1136/postgradmedj-2014-133195
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.
• Chapter 1, “The History and Interviewing Process”
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)
Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x
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.
Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3.
Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (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
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