Building a Health History Essay

Building a Health History Essay

CASE 3: Adolescent white male without health insurance seeking medical care for STI

Comprehensive health and risk assessment in the adolescent population is challenging, given the multiple issues manifesting during this developmental stage. Moreover, adolescents do not readily share personal information because they barely trust people and tend to be defiant, making them resist any intervention efforts in their lives. When conducting interviews to build health history with adolescents, important communication principles include trust, confidentiality, and a nonjudgmental attitude.

In the scenario, a white adolescent male seeks medical care for STI. With adolescent patients, it is crucial to make them feel comfortable first. I would achieve this by building rapport using compliments such as on dressing. I would also initiate small talk and ask the patient about home life and favorite past-times. Once I establish rapport, I will use open-ended questions and encourage the adolescent to talk freely. The communication techniques that will guide my interview include avoiding criticism, showing respect and genuine concern, giving friendly responses, and ascertaining privacy and confidentiality (Diamond-Fox, 2021). Additionally, adolescents have great independence and do not want to be treated like children; thus, I will address the patient as if I am having a conversation with an adult.

The patient does not have health insurance pointing to the possibility of coming from a vulnerable population of low socioeconomic background. I would assess the patient’s childhood background and educational background to understand the socioeconomic factors that might influence their health (Ball et al., 2019). I would also ask about the family’s status and whether both parents are present. I would assess challenges in accessing health services, basic needs, and also get information about the neighborhood (Srinath et al., 2019). I would also inquire about the kind of people he hangs out with; if they are involved in substance abuse and criminal activities. Finally, I will assess the possibility of substance use in the family (parents) and experiences of abuse and neglect.

The screening tools appropriate for adolescents are Rapid Assessment for Adolescent Preventive Services (RAAP), used to identify health risks, and HEeADSSS Assessment, which evaluates risk and protective factors to enable effective intervention. In addition, the CRAFFT Screening Test is also used with the adolescent population to identify problems and risks associated with drug use.

Based on the patient’s age, one of the major risks he is exposed to is substance abuse. According to the National Center for Drug Abuse Statistics (2022), 50% of teenagers have abused drugs and alcohol at least once. Teenagers are vulnerable to substance use because of peer pressure, the urge to experiment, ignorance about the effects, and involvement in criminal activities. For adolescents from low socioeconomic status, the risk of substance abuse is even higher (Farley, 2020). The second risk that the patient is exposed to is infectious diseases. The patient presents with the problem of STI, which means he engages in behavior that exposes him to the risk of sexually transmitted infections and can lead to contracting HIV and other chronic infections. Finally, the patient may be exposed to psychosocial issues common with adolescents.

The risk assessment instrument I would use is HEADSS, an interview instrument used to evaluate issues in an adolescent’s life. The instrument evaluates several components, including home, education/employment, activities, drugs use, sexuality, and mental health concerns (Ball et al., 2019).

Targeted Questions

1. Do you live at home with your parents? Are both your parents together?
2. What kind of people do you hang out with most?
3. Have you ever tried alcohol, marijuana, and any other hard substance?
4. Have you ever witnessed or been a victim of abuse in the past and present?
5. Do you use protection when engaging in intercourse with your girlfriend?
6. What do you know about sexually transmitted infections?
7. Have you ever felt like harming yourself or someone else?
8. Have you ever run into problems with law enforcement, leading to incarceration?

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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.

Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238.

Farley, H. R. (2020). Assessing mental health in vulnerable adolescents. Nursing, 50(10), 48-53. doi: 10.1097/01.NURSE.0000697168.39814.93.

National Center for Drug Abuse Statistics. (2022). Drug use among youth: Facts & statistics. Retrieved from National Center for Drug Abuse Statistics: https://drugabusestatistics.org/teen-drug-use/

Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian journal of psychiatry, 61(Suppl 2), 158–175. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_580_18.

 

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.

Photo Credit: Sam Edwards / Caiaimage / Getty Images
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.

CASE 3: Adolescent white male without health insurance seeking medical care for STI

 

Learning Resources

Required Readings (click to expand/reduce)

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)

Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0

Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015

Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238

Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.
• Chapter 2, “History Taking and the Medical Record” (pp. 14–27)

Required Media (click to expand/reduce)

 

URS_6512_Week_1_Discussion_Rubric

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Main Posting 45 (45%) – 50 (50%)
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. 40 (40%) – 44 (44%)
“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. 35 (35%) – 39 (39%)
“Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors. 0 (0%) – 34 (34%)
“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness 10 (10%) – 10 (10%)
Posts main post by Day 3. 0 (0%) – 0 (0%)
N/A 0 (0%) – 0 (0%)
N/A 0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response 17 (17%) – 18 (18%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. 15 (15%) – 16 (16%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. 13 (13%) – 14 (14%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. 0 (0%) – 12 (12%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response 16 (16%) – 17 (17%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. 14 (14%) – 15 (15%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. 12 (12%) – 13 (13%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. 0 (0%) – 11 (11%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. 0 (0%) – 0 (0%)
N/A 0 (0%) – 0 (0%)
N/A 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on three different days.