NURS 6512 Discussion: Building a Health History Instructions and Example Solution Provided
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.
Photo Credit: Getty Images/Caiaimage
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. Patient Profile to Use: 40-year-old black recent immigrant from Africa without health insurance
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.
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.
Resource List
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)
NURS 6512 Discussion: Building a Health History Example Solution
The scenario I was given for this week is an 80-year-old white male with angina who lives on a farm 80 miles from a healthcare center.
According to the National Institute on Aging (NIA), 25% of seniors aged 65 to 70 have hearing loss, while 50% of those over 75 have debilitating hearing loss. Talking clearly and slowly, looking at the patient directly, and reducing background noise are all ways of dealing with hearing loss (National Institute on Aging, n.d.-b).
Background noise could distract patients from listening to what you are trying to communicate with the patient. Sit facing the patient, employ active listening techniques, ask open-ended questions that might elicit a more thorough response, inquire about their functional status, and, if possible, request medical records from another provider before the appointment so that you can gather additional information that the patient may not provide to obtain an accurate medical history via interview (National Institute on Aging, n.d.-a).
When there is excellent communication between the practitioner and the patient, health assessment questions can be answered to the best of one’s ability. For the patient to grasp what you are asking or saying, the National Institute on Aging (n.d.-b) advises avoiding medical terms and adopting straightforward language and expressions.
The cardiovascular risk calculator from the ACC/AHA is the risk assessment tool I selected to employ for this patient. The patient’s angina complaint was why I decided on this tool. To ascertain the likelihood of a stroke, heart attack, or death from cardiovascular illness within the next ten years, persons should have a cardiovascular risk assessment (UpToDate, n.d.). To use this tool efficiently, this patient would require simple laboratory tests to determine his total cholesterol and HDL cholesterol. His medical history for diabetes, the drugs he is on now, his social history for smoking, and his current medications would all need to be evaluated by the healthcare professional (UpToDate, n.d.).
Age, race, and gender of the patient are all potential health hazards that should be taken into account. According to the Centers for Disease Control and Prevention, approximately 1 in every 4 American male fatalities are attributable to heart disease in 2021, and 7.7% of white males, or 1 in 13, had coronary artery disease. Diabetes history, a poor diet, being overweight, being inactive physically, and drinking too much alcohol are all potential risk factors for heart disease (Centers for Disease Control and Prevention, 2021). When beginning new drug management, this information should be carefully reviewed and may be obtained during the patient interview.
A few questions I would ask the patient are:
What medications are you now taking? Can I see them, please?
What do you consume in the morning? Lunch? Dinner?
Do you have any dietary or medicine allergies? What responses did you get?
Do you find it easy to stand up and move around or feel out of breath?
Do you experience breathing issues while lying on your back?
Any issues using the restroom?
Are there any aches or weakened muscles?
How does this pain feel when it is present? Does it extend to your arm, neck, or jaw?
Does it hurt or feel like someone is stabbing you?
How long does this discomfort linger before it stops?
Is there anything you do that affects it positively or negatively?
Do you consume alcohol, illegal substances, or smoke?
NURS 6512 Week 2: Functional Assessments and Cultural and Diversity Awareness in Health Assessment
DIVERSITY AND HEALTH ASSESSMENTS
May 2012, Alice Randall wrote an article for The New York Times on the cultural factors that encouraged black women to maintain a weight above what is considered healthy. Randall explained—from her observations and her personal experience as a black woman—that many African-American communities and cultures consider women who are overweight to be more beautiful and desirable than women at a healthier weight. As she put it, “Many black women are fat because we want to be” (Randall, 2012).
Randall’s statements sparked a great deal of controversy and debate; however, they emphasize an underlying reality in the healthcare field: different populations, cultures, and groups have diverse beliefs and practices that impact their health. Nurses and healthcare professionals should be aware of this reality and adapt their health assessment techniques and recommendations to accommodate diversity.
In this Discussion, you will consider different socioeconomic, spiritual, lifestyle, and other cultural factors that should be taken into considerations when building a health history for patients with diverse backgrounds. Your Instructor will assign a case study to you for this Discussion.
By Day 1 of this week, you will be assigned a case study by your Instructor. Note: Please see the “Course Announcements” section of the classroom for your case study assignment.
Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient assigned to you.
Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?
BY DAY 3 OF WEEK 2
Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
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!
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 1, “Cultural Competency”
This chapter highlights the importance of cultural awareness when conducting health assessments. The authors explore the impact of culture on health beliefs and practices.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
. Retrieved from https://npin.cdc.gov/pages/cultural-competence
This website discusses cultural competence as defined by the Centers for Disease Control and Prevention (CDC). Understanding the difference between cultural competence, awareness, and sensitivity can be obtained on this website.
United States Department of Human & Health Services. Office of Minority Health. (n.d.). A physician’s practical guide to culturally competent care. Retrieved June 10, 2019, from https://cccm.thinkculturalhealth.hhs.gov/
From the Office of Minority Health, this website offers CME and CEU credit and equips healthcare professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve.
NURS 6512 Week 3: Assessment of Nutrition in Children
Week 3: Assignment 1 Case Study Assignment: Assessment of Nutrition in Children
When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results.
Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process.
For this Assignment, you will consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.
To Prepare:
Review this week’s Learning Resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. You also will review examples of pediatric patients and their families as it relates to BMI.
Based on the risks you might identify consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
Consider how you could encourage parents or caregivers to be proactive toward the child’s health.
THE ASSIGNMENT
Assignment (3–4 pages, not including title and reference pages):
Assignment: Child Health Case:
Include the following:
An explanation of the health issues and risks that are relevant to the child you were assigned.
Describe additional information you would need in order to further assess his or her weight-related health.
Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.
Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.
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 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process.
Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth among the organ systems.
Download Student checklist: Health history guide. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Centers for Disease Control and Prevention. (2021, April 9). Childhood overweight & obesity.http://www.cdc.gov/obesity/childhood/
This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”
This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Week 1)
Chapter 5, “Pediatric Preventative Care Visits” (pp. 91 101)
NURS_6512_Week_3_Assignment_1_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning Outcome In 3–4 pages, address the following: An explanation of the health issues and risks that are relevant to the child you were assigned.
25 to >24.0 pts Excellent
The response clearly, accurately, and in detail explains the relevant health issues and risks for the assigned child.
24 to >23.0 pts Good
The response accurately explains the relevant health issues and risks for the assigned child.
23 to >17.0 pts Fair
The response vaguely and with some inaccuracy explains the relevant health issues and risks for the assigned child.
17 to >0 pts Poor
The response is inaccurate and/or missing explanations of the relevant health issues and risks for the assigned child.
25 pts
This criterion is linked to a Learning Outcome Describe additional information you would need in order to further assess his or her weight-related health.
25 to >24.0 pts Excellent
The response clearly and accurately describes detailed additional information needed to further assess the child’s weight-related health.
24 to >23.0 pts Good
The response accurately describes additional information needed to further assess the child’s weight-related health.
23 to >17.0 pts Fair
The response vaguely and with some inaccuracy describes additional information needed to further assess the child’s weight-related health.
17 to >0 pts Poor
The response is inaccurate and/or missing a description of additional information needed to further assess the child’s weight-related health.
25 pts
This criterion is linked to a Learning Outcome Identify and describe any risks, and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
20 to >17.0 pts Excellent
The response clearly and accurately identifies and describes in detail any risks to the child’s health. The response clearly and accurately identifies and describes in detail further information needed to gain a full understanding of the child’s health, with a detailed explanation of how to gather that information in a way that is sensitive to the child.
17 to >14.0 pts Good
The response accurately identifies and describes any risks to the child’s health. The response accurately identifies and describes further information needed to gain a full understanding of the child’s health, with a clear explanation of how to gather that information in a way that is sensitive to the child.1
4 to >13.0 pts Fair
The response vaguely and with some inaccuracy identifies and describes any risks to the child’s health. The response vaguely identifies and describes further information needed to gain a full understanding of the child’s health, with a vague explanation of how to gather that information in a way that is sensitive to the child.
13 to >0 pts Poor
The response identifies inaccurately and/or is missing descriptions of any risks to the child’s health. The response identifies inaccurately and/or is missing descriptions of further information needed to gain a full understanding of the child’s health, with an inadequate or missing explanation of how to gather that information in a way that is sensitive to the child.
20 pts
This criterion is linked to a Learning Outcome Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.
10 to >9.0 pts Excellent
The response clearly and accurately lists three or more specific questions that would gather more information about the child. Specific questions are carefully worded to clearly demonstrate sensitivity to the parent(s) or caregiver(s) of the child.
9 to >8.0 pts Good
The response lists three specific questions that would gather more information about the child. Specific questions are worded to demonstrate sensitivity to the parent(s) or caregiver(s) of the child.
8 to >7.0 pts Fair
The response lists three questions with wording that is vague and lacking specificity for gathering more information about the child. Some wording of the questions lacks sensitivity to the parent(s) or caregiver(s) of the child.
7 to >0 pts Poor
The response lists two or fewer confusing or inadequate questions, or is missing questions, for gathering more information about the child. Wording of questions provided lacks sensitivity to the parent(s) or caregiver(s) of the child.
10 pts
This criterion is linked to a Learning Outcome Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.
5 to >4.0 pts Excellent
The response clearly describes two or more detailed strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight.
4 to >3.0 pts Good
The response describes at least two strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight.
3 to >2.0 pts Fair
The response vaguely describes two strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight.
2 to >0 pts Poor
The response inadequately describes one strategy or is missing strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight.
5 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 are provided that delineate all required criteria.
5 to >4.0 pts Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 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 are vague or off topic.
2 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 were 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 >4.0 pts Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 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, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts Excellent
Uses correct APA format with no errors.
4 to >3.0 pts Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
Week 3: Assignment 2 Digital Clinical Experience (DCE): Health History Assessment
A comprehensive health history is essential to providing quality care for patients across the lifespan, as it helps to properly identify health risks, diagnose patients, and develop individualized treatment plans. To effectively collect these heath histories, you must not only have strong communication skills, but also the ability to quickly establish trust and confidence with your patients. For this DCE Assignment, you begin building your communication and assessment skills as you collect a health history from a volunteer “patient.”
To Prepare
Review this week’s Learning Resources as well as the Taking a Health History media program, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation (Required, you will not be able to access the Health History without completing the requirements).
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve total score of 80% or better(includes BOTH DCE and Documentation), but you must take all attempts by the Week 4 Day 7 deadline.
Tina Jones Health History Transcript
Started: Sep 18, 2023 | Total Time: 292 min
All Lines (330)
Interview Questions (280)
Statements (38)
Exam Actions (12)
