NRS 420 Health History Assessment Paper
NRS-420: Health Assessment imparts the student with critical knowledge on the methods of health history taking, physical examination skills, and documentation of findings. Students integrate assessment skills and clinical judgment/reasoning in identifying actual or potential health problems and needs across the life span. Health promotion strategies are incorporated to provide for the unique needs of the individual, ensuring person-centered care. The course emphasizes the importance of providing compassionate care dealing with diversity, equity, and inclusion. Students design plans of care based on evidence-based research and practice.
Building a Health History Example Paper
When conducting an interview with a 22-year-old LGBTQIA female Hispanic immigrant living in a middle-class suburb, it is essential to employ communication techniques tailored to her unique experiences and background. These communication techniques are not mere formalities but integral to ensuring that the patient feels understood, respected, and valued. In a healthcare setting, where vulnerability often accompanies patients, the way a practitioner communicates can significantly impact the effectiveness of care and the patient’s willingness to engage in the treatment process.
The first cornerstone of effective communication is empathetic listening (Ball et al., 2023). This goes beyond merely hearing the words the patient says, it involves understanding the emotions and experiences behind those words. For a young LGBTQIA woman who is also an immigrant, there may be layers of complexity in her experiences that necessitate a particularly sensitive and non-judgmental approach. She may have faced challenges related to her sexual orientation, gender identity, cultural adaptation, and possibly discrimination or social exclusion. Understanding these layers through empathetic listening helps build trust and a therapeutic relationship (Sullivan, 2019).
Cultural competence plays a critical role in this interaction. It involves an understanding and respect for the patient’s Hispanic heritage. Each culture has its own set of health beliefs, practices, and values, which can significantly influence a patient’s approach to healthcare (Ball et al., 2023). By acknowledging and respecting these cultural nuances, a healthcare provider can create a more welcoming and comfortable environment for the patient. This might involve understanding specific health beliefs prevalent in the Hispanic community or being aware of the cultural norms that might influence her health behaviors.
Inclusive language is particularly important considering the patient’s LGBTQIA identity (Bingham & Heavey, 2023). This involves using language that respects and affirms her gender identity and sexual orientation. Inclusivity in language is not just about political correctness; it is about creating a safe space where the patient feels seen and respected as her whole self. This includes avoiding assumptions about her relationships, preferences, or experiences based on her sexual orientation or gender identity.
Given her status as an immigrant, there might be language barriers or differences in understanding healthcare terminologies. Therefore, communication should be in clear, simple language. Using visual aids or translation services might be necessary to ensure that she fully understands the information being shared. This clarity in communication is not just about overcoming language barriers; it is about ensuring that the patient is fully informed and can actively participate in her healthcare decisions (Sullivan, 2019).
Targeted Questions:
Health history and present concerns: “Can you share any health concerns you are currently experiencing or any significant past medical history?”
Support system: What kind of support system do you have? This can include friends, family, or community groups.
Experience as an immigrant: How has your experience been as an immigrant in this community? Are there any specific challenges or positive experiences you would like to share?
LGBTQIA-specific concerns: As a member of the LGBTQIA community, have you faced any challenges related to this aspect of your identity, either personally or in accessing healthcare?
Cultural and personal values: How do your cultural background and personal values influence your approach to health and healthcare?
Conclusion
The interview with a 22-year-old LGBTQIA female Hispanic immigrant in a middle-class suburb requires a communication approach that is empathetic, culturally sensitive, inclusive, clear, and encouraging open dialogue. By employing these techniques, a healthcare provider can ensure that the patient feels respected, understood, and comfortable sharing her experiences and concerns. This approach not only enhances the quality of the healthcare provided but also strengthens the patient-provider relationship, which is fundamental to effective healthcare delivery.
References
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.). Elsevier Mosby.
Bingham, K. W., & Heavey, E. (2023). Creating a friendly healthcare environment for LGBTQIA+ patients. Nursing, 53(1), 34–38. https://doi.org/10.1097/01.NURSE.0000903984.79871.c3
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis.
Example Reflection Paper on Taking a Health History
While building the patient’s health history, I used both principles from science and art concepts of care. The process was similar to a job interview apart from the purpose of the information derived from answering the questions. This interview aimed to assess the risks and social determinants of health to establish an accurate and reliable health history. Therefore, hard questions or questions deemed as sensitive or personal were necessary.
Experiences
Developing the script for the interview required both critical and reflective thinking to incorporate goal-oriented questions while simultaneously considering the outcomes of the questions for the patient. The inclusion of the ‘hard’ questions was the critical step. Translating the evidence from clinical literature to suggest personal and direct closed questions was the first step towards developing.
Teenage pregnancy impacts both the teenager and parents, guardians, or the custodian economically and socially. To the teenager, the health burden of adolescent pregnancy increases due to the imbalance between the physiological demands and available physical and physiological body supply in that age group. Therefore, holistic care should take into account these factors.
In developing a health history, I targeted the questions toward establishing additional risks that could worsen these imbalances in biophysical and physiological imbalances in demand and supply. I also focused the interview on establishing a ground for planning for prenatal and postnatal care interventions and evaluation. Including the emotional outcomes of the health problem for the patients was guided by the idea that during the teenage period, physiological and social outcomes can cause body image and mood outcomes. Therefore, I believe that I maximized opportunities to plan holistic care through this history-taking.
Asking the Questions
Asking the questions would require setting the patient in the right mind and mood. Difficulties with had questions are related to the patient and clinician’s perceived impacts on the self-image. Fear of breaking the trust between the clinician and the patient also complicates asking hard questions. The clinician will target hornet answers and build a reliable health risks profile.
The patient can withhold honest responses to the questions due to a lack of trust that the clinical will maintain confidentiality or may judge them (Nasirian et al., 2018). Therefore, reassurance and active listening are some of the strategies that would improve the outcomes of the actual interview. The positioning with the patient, the body language, facial expressions, the tone of the questions, and the tone of the clinician’s responses are critical in establishing authentic and truthful responses from the patient (Ball et al., 2018).
The presence of a guardian in the interview suggests they would help corroborate the health history but may also limit the patient’s confidence in responding to sensitive questions. Therefore, the environment in terms of noise levels, lighting, and presence of third parties are key concepts I may consider when redoing the interview differently (Flugelman, 2021).
In sum, the development of the interview is artistic and scientific. Merging scientific and interpersonal interaction principles to achieve a reliable health history was the critical underpinning of the interview script development. Environmental considerations would be vital in influencing the authenticity and reliability of patient responses and establishing a therapeutic relationship to achieve different outcomes.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2018). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Mosby.
Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505
Nasirian, M., Hosseini Hooshyar, S., Haghdoost, A. A., & Karamouzian, M. (2018). How and where do we ask sensitive questions: Self-reporting of STI-associated symptoms among the Iranian general population. International Journal of Health Policy and Management, 7(8), 738–745. https://doi.org/10.15171/ijhpm.2018.18
NRS 420 Health History Assessment for Tina Jones Example Transcript
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