Discussion: Building a Health History

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.

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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.

Communication Techniques

Building a history during the interview process is a crucial component of patient assessment for delivering high-quality care. The first encounter with the patient sets the tone for a successful partnership. The health care provider should create a patient-centered atmosphere. The Institute of Medicine (IOM) defines patient-centered care as “respecting and responding to patient’s wants, needs, and preferences so that they can make choices in their care that best fit their circumstances” (Jawad Hashim, 2017). The provider should be open, flexible, and eager to deal with all the patient’s questions, concerns, explanations. The clinicians responsibility is to create a calm, quiet environment with their patients to establish a trusting relationship (Ball, et al., 2019). When communicating with individuals of different cultures we must assure there is cultural competence as I would have to do when communicating with my patient who is an older Asian American woman. I can provide my patient the opportunity to fully understand my interview and address any question by keeping calm, using open ended, maintaining eye contact and avoiding medical jargon (Ball, et al., 2019).

The Interview

Asian women are affected by breast cancer 50- 60 % more than other cultures(Zhao & Conard, 2016). The percentage Mammography screenings are affected by health disparities, modesty, religious belief, and cultural norms of Asian American women. Asian American face many challenges in obtaining healthcare and completing screening (Weng & Wolf, 2016).When interviewing this patient I must ensure that I address any familiar history or patient history of breast cancer. Understanding this aspect of inequality of healthcare services for Asian American women should impact my cultural competence in opening a dialogue that is critical. It is my responsibility to inquire about any past or familial history of breast cancer.

Risk Assessment

With her age and cultural background the patient is at increased risk for breast cancer and osteoporosis. As her provider it is imperative that I order diagnostic tests and screening exams. , 1. Chem Panel to evaluate hormone levels, electrolytes- phosphorus, calcium, and calcitonin

n.2. Bone density exam 3. Mammogram . To ascertain any mammogram results from their past for comparison.After all the tests have been completed I will have the patient make a follow up appointment to discuss the results and develop a treatment plan if one is needed.

5 Targeted Questions

1. What has brought you into the clinic today?

2. Do you have any chronic medical conditions?

3. Do you have medications that you are taking at this time?

4. Have you ever had a bone scan in the past?

5. When was your last mammogram?

6. What are your main concerns today?

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.

Jawad Hashim, M. (2017). Patient-Centered Communication: Basic Skills. American Family Physician, 95(1), 29–34.

Weng, S. S., & Wolfe III, W. T. (2016). Asian american health inequities: An exploration of cultural and language incongruity and discrimination in accessing and utilizing the healthcare system. International Public Health Journal, 8(2), 155–167.

Zhao, M., & Conard, P. L. (2016). Content validity of a screening instrument for breast cancer early detection among asian american women: the cultural health and screening mammography belief scale. Journal of Nursing Measurement, 24(3), 356–364.