Building a Health History
As a nurse practitioner, it is important to understand that many considerations have been considered when assessing patients as no two individuals are the same. Therefore, consideration should be given to the differences in the patient. These differences are not limited to race, culture, age, gender, and socio-economic background. Per Donnelly & Martin (2016) in obtaining a proper assessment of a patient leads to proper treatment of the patient.
Considering Each Case History
In building a health history, consideration should be like each of the demographic population. Different interviewing and assessment techniques that will allow them to be comfortable and willing to share the necessary information that will build their health history. For instance, when assessing a seventy-six-year-old black male with disabilities living in an urban setting, these factors should be noted, age, demographic, cognitive awareness, and lifestyle, the same can be said for all the other case history. The seventy-six-year-old male will require the nurse practitioner to be focused on then when speaking. They should speak slowly and with clarity, and properly pronouncing words, as the patient may have a problem processing conversation quickly. According to Ball, Dains, Flynn, Solomon & Stewart (2015), the adolescent boy may need time to open, so the interview and assessment process should not be rushed. The fifty-five-year-old Asian female living in a high-density poverty complex will need to be addressed with respect. The nurse practitioner should understand that the pre-school age white female living in a rural community may need communication through play to alleviate their fears. The sixteen-year-old teenager living in an inner-city neighborhood will need reassurance and non-judgmental evaluation. Understanding age, gender, ethnicity, and environment will allow the practitioner to know how to approach each patient case.
Risk assessment Instruments
There are many risk assessment instruments that can be used for screening. These are important in building the foundational health history as it can show the progression of patient development as well as decline. In the evaluation of the patient who is seventy-six-year-old male is, a fall risk assessment would be appropriate, questions regarding last fall if any, and type of medications. An STD screening would be appropriate for the adolescent Hispanic/ Latino boy asking a question regarding sexual activity and how many sexual partners. A TB and pneumonia screening should be done for the Asian female asking question relating to exposure and symptoms. For the pre-school age white female would benefit from a developmental screening, parents involvement is usually necessary as answers to the question relating to achievement of the milestone is gained through them; and, the pregnant sixteen-year-old could do a prenatal and nutrition screening, questions relating to nutrition, supplements, feelings regarding pregnancy.
Pregnant at Sixteen in the Inner-city
According to According to Ball, Dains, Flynn, Solomon & Stewart (2015), using effective tools is helpful in gaining the most information necessary information to build not only a positive relationship; but, also necessary heal history. One of the screening that could be used for the 16-year-old white pregnant teenager living in an inner-city neighborhood would be HEEADSSS (home environment, education, eating, activities, drugs, sexuality, suicide/depression, safety from injury and violence). This instrument is appropriate for this patient for many reasons, given that at this age and stage of development and background patient may be having an identity crisis, unsure about her pregnancy, and uncertain home environment as well as any or all the other issues in the screen tool. The risk assessment instrument could include an HIV risk assessment as at this teenager was likely engaging in an unprotected sexual activity. As there may be limited knowledge about the potential father, doing an HIV risk assessment can help to protect the fetus from possible infection. Proper screening is important as highlighted by Duberstein and Jerant (2014) journal article regarding suicide prevention; whereby the lack of proper screening as let to a steady incline of suicide rates.
Five Targeted Questions
- What are your expectations regarding your visit today?
- Was the sex consensual?
- When was your menstrual period?
- How do you feel about your pregnancy?
- Who you parents and or partner able to provide support?
Asking targeted question will allow the provider the capability to expand the interaction, promoting follow-up questions and gaining more information.
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.
Donnelly, M., & Martin, D. (2016). History taking and physical assessment in holistic palliative care. British Journal of Nursing, 25(22), 1250.
Duberstein, P., & Jerant, A. (2014). Suicide Prevention in Primary Care: Optimistic Humanism Imagined and Engineered. JGIM: Journal of General Internal Medicine, 29(6), 827. doi:10.1007/s11606-014-2839-4
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