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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)Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … 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, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- xWu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508–513.Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3.Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8Shadow Health Support and Orientation ResourcesDiscussion: Building a Health HistoryEffective 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/CaiaimageTo 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.SAMPLE 1 FROM THE SAME ASSIGNMENT PLEASE FOLLOW THISNURS 6512N: Advanced Health Assessment and Diagnostic ReasoningWeek 1: Building a Comprehensive Health HistoryBuilding a Health HistoryBall et al., (2015), acknowledges that building a health history is more than just asking patients questions. The health history interview is a conversation with a purpose, “primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity, and partnership” (Ball et al., 2015, p. 1). Using techniques that promote trust and convey respect allows the patient’s story to be told. Establishing a supportive interaction helps the patient feel more at ease when sharing information creating a foundation for therapeutic clinician-patient relationships.Patient ScenarioA 76-year-old Black/African-American male with disabilities living in an urban setting. Because the geriatric a multidimensional assessment the advance practice nurse must “understand the physiologic changes unique to this population, as well as the differences between normal aging-related changes and health alterations caused by illnesses and social changes” (American Nurses Association, 2011, para. 2). Before the physical assessment begins, collection of the health history by interviewing the patient (and family members, if present) with a patient centered open-ended question approach would be used. The information gathered will help focus on particular areas of concern during the physical examination. This technique will also aid in building a rapport, encourage compliance with treatment and targets the patient’s concerns.Interview and Communication TechniquePatient centered interview and communication technique allows the patient a platform to speak freely and provide relevant information. To promote an efficient information exchange and enhance rapport with the patient, distractions would be minimized. Facing the patient, a reason for the interview and overview of the process would be explained. Addressing the patient open-ended questions would be presented clearly. Paraphrasing would be used to attain clarity which is also important in the development of developing building rapport. A collaborating technique would also be used to aid in developing common goals which affirms ways to work together to improve the well-being of the patient.Risk Assessment InstrumentThe comprehensive geriatric assessment (CGA) tool would be the risk assessment instrument utilized on this patient. This assessment instrument is a process which is used to manage frail or vulnerable older adults. The CGA is a comprehensive assessment that looks not only at a patient’s physical medical condition but also their mental health, functionality, social circumstances, and environment. “By assessing each of these domains of health, a comprehensive assessment can be made, and the full bio-psycho-social nature of the individual's problems can be identified” (Welsh et al., 2014, p. 290). The CGA identifies risks such as falls, functional status, ADL’s capability, gait, social support, and financial status that affect elderly patients. Geriatric conditions such as functional impairment and dementia are common and frequently unrecognized or inadequately addressed in older adults. Deck et al., (2015) acknowledges that geriatric screening tools such as the CGA provides valuable information by identifying patients at risk for functional decline or decline in quality of life, prompting physicians to consider different aspects of functioning. Identifying geriatric conditions by performing a geriatric assessment can help clinicians manage these conditions and prevent or delay their complications.Five Targeted Questions1.) Do you have any difficulties with completing your daily activities such as grooming, meal preparations, grocery shopping, taking medication, bathing, etc.?2.) Do you have a support system?3.) What are things that make you happy/sad?4.) Do you have any problems ambulating in your home (assessing for falls and any ambulatory assistance aids)?5.) Do you have any concerns or further questions for me at this time?ReferencesAmerican Nurses Association. (2011). Geriatric assessment: Essential skills for nurses.American Nurse Today, 6(7). Retrieved fromhttps://www.americannursetoday.com/geriatric-assessment-essential-skills-for-nurses/Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide tophysical examination (8th ed.). St. Louis, MO: Elsevier Mosby.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 declinein 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 fromhttp://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0241-xWelsh, T. J., Gordon, A. L., & Gladman, J. R. (2014). Comprehensive geriatric assessment-aguide for the non-specialist. International Journal of Clinical Practice, 68(3), 290-3. doi:10.1111/ijcp.12313 Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282277/
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