Building A Comprehensive Health History  • Online Nursing Essays

Sample Answer for Week 1: Building a Comprehensive Health History Included After Question

Week 1: Building a Comprehensive Health History 

According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in the United States. One of the most admired nursing skills is the ability to put patients at ease. When patients enter into a health care setting, they are often apprehensive about sharing personal health information. Caring nurses can alleviate the hesitance of patients and encourage them to be forthcoming with this information. 

The initial health history interview can be an excellent opportunity to develop supportive relationships between patients and nurses. Nurses may employ a variety of communication skills and interview techniques to foster strong bonds with patients and to effectively facilitate the diagnostic process. In conducting interviews, advanced practice nurses must also take into account a range of patient-specific factors that may impact the questions they ask, how they ask those questions, and their complete assessment of the patient’s health. 

This week, you will consider how factors such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how these factors influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history. 

Learning Objectives 

Students will: 

Analyze communication techniques used to obtain patients’ health histories based upon age, gender, ethnicity, or environmental setting 
Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information 

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Learning Resources  

Required Readings 

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Chapter 1, “The History and Interviewing Process” (pp. 1–21)  

  

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 26, “Recording Information” (pp. 616–631)  

  

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 1, “Medicolegal Principles of Documentation” (pp. 1–14 and abbreviations, pp. 19) 

  

Chapter 2, “The Comprehensive History and Physical Exam” (pp. 23-32) 

Note about Uploading Media: 

Please refer to the Kaltura Media Uploader page located in the course navigation menu.. The documents on this page provide guidance on how to upload media for your Health Assessment Videos assignments for this course. 

Deck, L., Akker, M., Daniels, L., DeJonge, E. T., Bulens, P., Tjan-Heijnen, V., L Van Abbema, D. & 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(30), 1–12. doi 10.1186/s12875-015-0241-x. Retrieved from http://bmcfampract.biomedcentral.com/articles/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. Post Grad Medical Journal, 91 (1079), 508–513. doi:10.1136/postgradmedj-2014-133195. Retrieved from http://pmj.bmj.com/content/91/1079/508 

Lushniak, B. D. (2015). Surgeon General’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, 130(1), 3–5. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245280/ 

Jardim. T. V., Sousa, A., Povoa, T., Barroso, W., Chinem, B., Jardim, L., Bernardes, R., Coca, A., & Jardim, P. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Family Practice, 15(1111), 1–7. doi 10.1186/s12889-015-2477-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642770/ 

Optional Resources 

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical. 

Chapter 2, “History Taking and the Medical Record” (pp. 15–33) 

A Sample Answer For the Assignment: Week 1: Building a Comprehensive Health History 

Title: Week 1: Building a Comprehensive Health History 

Interview and Communication Techniques 

            During the interview of a 16-year-old white pregnant teenager living in an inner-city neighborhood, the techniques to build a health history should be thoughtfully and compassionately carried out.  Firstly, it is recommended during any interview that it take place in a comfortable setting.  It is advisable to stray away from equipment or desks/tables unintentionally creating a barrier between the provider and the patient.  The provider should sit eye level with the patient, relaxed, with a calm tone of voice.  These techniques will help the provider establish a relationship with the patient; gaining the patient’s trust, thus obtaining an accurate and thorough health history (Ball, Dains, Flynn, Solomon, & Stewart, 2015). 

Secondly, the patient is an adolescent still.  When the provider introduces him/herself to the patient, anyone accompanying the patient should also be identified and addressed by name.  If there is a parent with the patient, the provider should learn the parent’s name and involve the parent.  However, a patient over the age of seven can typically be a dependable reporter for health information and the patient should be allowed confidentiality and privacy.  Adolescents may be reluctant to disclose certain information in front of a parent and wish to speak with the provider privately.  It is important to honor these wishes yet involve the parent and the patient’s support system in the patient’s care.  Despite the pregnancy, this patient still can struggle with normal adolescent behaviors and experiences in which risk factors such as poor self-esteem and peer pressure must also be recognized.  It is important to incorporate these techniques into practice so that these risk factors can be identified and help and prevention measures provided (Ball et al., 2015). 

Thirdly, although an adolescent, this patient is pregnant.  Obtaining her health history regarding her pregnancy, any problems or complications thus far, menstrual and gynecologic history, and family history of genetic conditions or pregnancy related complications is vital.  This helps provide a direction for the appointment and future appointments, as well as identification of any health risks currently or potentially in the future (Ball et al., 2015).  Medical conditions such as diabetes or cardiac problems, risks for preterm labor, being pregnant with multiples, or any condition or issue which classifies the pregnancy as high risk, may prompt the need for a provider who cares for high-risk pregnancies (Fuentes, 2018).  Again, while obtaining her health history removal of any physical barriers such as electronic devices will help the patient feel more comfortable during the appointment, especially when talking about any sensitive issues or concerns (Ball et al., 2015). 

Risk Assessment Tool 

A risk assessment screening tool that could be utilized during the interview process with this patient would include the HITS screening tool for domestic violence.  The HITS screening tool includes questions for the patient, which asks if her partner has physically hurt her, insulted or belittled her, threatened her, or screamed at her in the past year (Ball et al., 2015).  As a 16-year-old, female gender, and pregnant, this patient is at an increased risk for intimate partner violence (IPV).  Intimate partner violence can have a significant consequence on an individual’s health.  These negative health risks can include chronic, acute, or fatal effects.  In regards to this particular patient’s pregnant health status, some negative health consequences can include an unintended or unwanted pregnancy, pregnancy complications, or miscarriage or abortion.  Additionally, this patient is at risk for sexually transmitted infections (STIs), sexual dysfunction, vaginal bleeding, vaginal or pelvic infections, multiple sexual partners, are at increased risk of having abusive partners in the future, and less likely to use contraception (World Health Organization, 2012).  It is imperative to ask questions when building a health history in order to assess the patient’s health risks.  Five questions that could be asked of this patient include:  

“Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?”  
“Do you feel safe at home or in your current relationship?”  
“Did you want to, or were you forced or talked into having sex?”  
“Is alcohol or drugs part of the problem?”  
“Has it gotten worse lately?”  

Answering “yes” to any of these questions warrants further evaluation (Ball et al., 2015). 

  

References 

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s 

guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby. 

Fuentes, A. (2018). Medical care during pregnancy. KidsHealth. Retrieved from 

https://kidshealth.org/en/parents/medical-care-pregnancy.html

World Health Organization. (2012). Understanding and addressing violence against 

women: Health consequences. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/77431/WHO_RHR_12.43_eng.pdf;jsessionid=9B21862A7D4A6F36422173D14595A05E?sequence=1