Building a Health History

Assigned Patient: Adolescent Hispanic/Latino boy living in a middle-class suburb
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.
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.
Please use a Heading for each major part of the assignment!
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Solution
Building A Health History: Adolescent Hispanic/Latino Boy Living in A Middle-Class Suburb
Building a Health History
Building a comprehensive and reliable patient health history is the foundation for developing a successful plan of treatment for each patient and is a skill expected of the APRN (Ewulonu, 2021). In this way, we gain a better understanding of our patients, their previous concerns and problems, and how those issues impact their current functioning. Considering that the patient is an adolescent Hispanic male, I begin by inquiring whether he is well acquainted with English, and in case he doesn’t, I will consider hiring an interpreter. I have to be culturally proficient to avoid unnecessary misunderstandings. I may be able to achieve this through sympathizing with his ancestry, sexuality, social status, race, and ethnic background.
Communication Techniques
Adolescence is a period of growth and development that occurs between childhood and adulthood. It is the most vulnerable stage in life for young adults as most of them are often unwilling to participate in any kind of communication. Therefore, obtaining information from them can be challenging. If the patient’s parents are present, I will inquire about the patient’s chief complaints thereafter request their permission to examine the patient their absence (Khullar, 2019). I will initiate the conversation by asking the patient about his day-to-day activities. I have to respect his opinions to acquire his trust. If I am confronted with quietness, I must appreciate it while also discerning whether the quietness is the result of anger, remorse, or simply an unwillingness to converse. My primary aim will be to learn more about his concerns and to show genuine interest and inquiry. I will use comprehensible language. I shall strive to preserve the peace. I will listen carefully to what the patient would have to say. After discovering the major concern, I would go on to more sensitive areas such as sex, drug, or alcohol use.
Risk Assessment Tool
Since adolescents are prone to risky behavior, it is critical to screen him for it. For his case, I would utilize the HEEADSSS screening tool for adolescence. This will help me to understand more about his upbringing, education, employment, eating habits, hobbies, and aspirations (Smith & McGuinness, 2017). I may also discover about his drug use, sexuality, and suicidal thoughts, as well as if he is safe from danger and aggression.
Some of the questions I would ask the patient are as follows:
How is life at home?
How are things going at school?
Tell me about your acquaintances.
What kind of computer and electronic games do you enjoy playing?
What are your key skills?
These open-ended questions will allow my patient to express concerns that are bothering him (Harrison & Handley, 2017).
References
Ewulonu, U. C. (2021). Utility of a psychosocial assessment during an acute care hospitalization. Current Problems in Pediatric and Adolescent Health Care, 100998.
Harrison, D. S., & Handley, M. (2017). Evaluation of a new genetic family history screening questionnaire for identifying Lynch syndrome. The Nurse Practitioner, 42(8), 48-51.
Jamalimoghadam, N., Yektatalab, S., Momennasab, M., Ebadi, A., & Zare, N. (2019). Hospitalized adolescents’ perception of dignity: a qualitative study. Nursing Ethics, 26(3), 728-737. https://journals.sagepub.com/doi/abs/10.1177/0969733017720828
Khullar, D. (2019). Building trust in health care—why, where, and how. JAMA, 322(6), 507-509. https://jamanetwork.com/journals/jama/article-abstract/2738392
Smith, G. L., & McGuinness, T. M. (2017). Adolescent psychosocial assessment: the HEEADSSS. Journal of psychosocial nursing and mental health services, 55(5), 24-27. https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.14675