Building a Health History Assignment Paper
Taking a Health History: Building a Health History: Asking Difficult Questions
The critical task of obtaining a patient’s health history falls within the purview of a nurse. When gathering information about a patient’s medical history, a healthcare professional has to be attentive in order to address difficult questions with decency, subtlety, and dignity. This is because the patient could find it difficult to respond appropriately to such challenging questions. It is the responsibility of the healthcare professional to establish a secure setting they may have a meaningful and comprehensive discussion with the patient Building a Health History Assignment Paper
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Interview Script
Medical History
· Do you currently suffer from any illnesses or conditions?
· Have you ever had any serious medical issues?
· Have you ever been hospitalized?
· Have you ever had surgeries?
· Are your vaccinations current?
Medications and Allergies
· Are you using any prescription medications?
· Are you using OTC medications, supplements, or vitamins?
· Do you suffer from any allergies? Building a Health History Assignment Paper
Substance Use
· Do you use alcohol?
· Do you use tobacco?
· Have you ever used marijuana?
· Do you use illicit drugs?
Menstrual History
· When did you first have a period?
· Are your menstrual periods regular?
· How long does your period typically last?
· Is period-related pain a common occurrence?
· Do you spot or bleed between periods?
Sexual History
· Do you have a sexual partner?
· When was your last sexual encounter?
· Do you have vaginal sex?
· Do you have issues with your sexual life?
· Have you ever had a pap smear?
· Have you been tested for STDs? Building a Health History Assignment Paper
Reflection
The task of generating the interview script was far more difficult than I expected. When conducting a comprehensive health history interview, the nurse practitioner has to pay attention to a great deal of information across a variety of different domains. Because of the delicate nature of the information, obtaining a complete evaluation from the patient might be challenging in certain domains. These domains include the patient’s sexuality, history of pregnancy, drug use, psychological wellbeing, and genital hygiene. When healthcare professionals first meet patients, they are responsible for cultivating an atmosphere in which the patients will be at ease sharing all of their private information and will have faith that the information would not be shared with anyone outside the hospital until it is absolutely essential to do so. It might be challenging for nurses to ask patients questions regarding their sexual health during patient interviews. This occurs as a result of a variety of issues, including a shortage of time, inadequate training, apprehension over embarrassment or invasion of privacy, differences in gender, age, or culture, and so on (Brooks et al., 2019)Building a Health History Assignment Paper. The trust placed in a medical provider by a patient is a significant and weighty obligation for that provider. This is because healthcare practitioners need the trust of their patients to work with them on their appropriate care approaches. The objectification of the female body may be a highly apparent and unavoidable phenomenon for women. As a result, it is incumbent upon the physician to recognize and work to mitigate the impact of such circumstances (Schuiling & Likis, 2022). This is dependent on the power distinctions that exist between the person providing care and the person receiving care, as well as the function that practitioners play in providing comprehensive patient care for the women they treat.
It may be possible to determine the appropriate phrases to assist in assessing sensitive areas by making use of the many resources that are available to healthcare professionals. Alcohol use is one of these areas. In this particular case, making use of the Alcohol Use Disorders Identification Test (AUDIT) has been shown to be effective. The World Health Organization (WHO) created this screening instrument, which consists of 10 questions, to evaluate the intake of alcohol, drinking habits, and alcohol-related issues (Higgins-Biddle et al., 2018). The fact that the health professional has access to a tool that has been phrased in a way that is considerate of the patient is a significant benefit. Due to AUDIT’s national accreditation, healthcare professionals won’t need to be concerned about whether or not they are asking sensitive questions in the right way or whether or not they will set off a variety of emotions in patients. If healthcare professionals use the terminology that is provided on the instrument, they will have the support of the organizational body that was responsible for developing the instrument Building a Health History Assignment Paper.
One more strategy is something that my preceptor performs with his clients, and I find it useful. During the course of a physical exam, my preceptor would always interact with the patient by asking them questions. for example, in order to evaluate a client’s level of physical activity throughout the transition from lying down to sitting up and pushing themselves back up, he evaluates the client’s capacity to use their muscles. During the time that the patient is resuming an upright posture, a healthcare provider can make a remark on how simple or challenging it was for the client to change postures and inquire about the client’s normal regimen of physical activity.
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Smiling, making sure I establish eye contact with the client and listening attentively to the client’s answers are some of the things I intend to do differently while taking the health history. When the patient is addressing personal and private questions, effective nonverbal communication is critical in all interactions. As such, I t is imperative that healthcare professionals be aware of the nonverbal cues that they are sending to clients. The honesty and frankness with which patients reveal their sexual practices can be influenced by social norms as well as personal views (Brooks et al., 2019). For instance, when young women are questioned about the number of sexual encounters they have had, they may lie constantly about their experiences.
Overall, when building a patient’s health history during a patient interview, it is critical to provide the patient with a sufficient amount of time to answer questions (Schuiling & Likis, 2022). As a result, the patient will have enough opportunity to discuss any and all of their issues throughout this period. In my view, the script I developed was informative because of its design and categorization, which made it simpler for the patient to answer the questions. The format of the interview script should be based on a set of key questions, but it should also be flexible enough to adapt to the replies and requirements of individual patients.
References
Brooks, L. A., Manias, E., & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26(3), 383-391. https://doi.org/10.1016/j.colegn.2018.09.007
Higgins-Biddle, J. C., & Babor, T. F. (2018). A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: Past issues and future directions. The American Journal of Drug and Alcohol Abuse, 44(6), 578-586. https://doi.org/10.1080/00952990.2018.1456545
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.
Module 1 Assignment: Taking a Health History: Building a Health History: Asking Difficult Questions Much of an archeologist’s work is done under the mantra “proceed with caution.” Archeologists must dutifully secure permissions to access sites. They also must exercise extreme caution when excavating or analyzing in a lab to avoid potential damage to historical artifacts. Likewise, nurse practitioners must proceed with caution when building a patient’s health history. Important questions can be difficult for both nurse and patient. Care must be taken to approach such questions with dignity, tact, and respect to create an environment conducive to productive conversations. For this Assignment, you will develop a script to be used to interview a volunteer serving in the role of patient. To prepare: Review the Ewing (2004) questionnaire found in this week’s Learning Resources and consider the difficult questions you might have to ask when you take a patient’s complete health history. Review the screening tools found in the Learning Resources and consider how you might use an app or tool to assist in screening. Review the media programs related to a vaginal exam, pap test, and breast exam Building a Health History Assignment Paper.
Review the health history guide presented in Chapter 6 of the Schuiling & Likis (2017) text and consider how you would create your own script for building a complete health history. (Note: You will also find the Health History Form in Chapter 6) Provide all the components of a complete gynecologic health history. Include considerations for special populations such as LGBTQ+ individuals. What health maintenance guidelines should be included for initial and follow up might be needed for follow-up assessments? (i.e., bone density test, Gardasil vaccine, shingles, etc.)? What questions would you consider in your patient’s complete health history? For example What is your patient’s living situation? Do they have stairs? Do they live by themselves? Do they have a working refrigerator? Develop your own script for building a complete health history and as you create your script, consider the difficult questions you want to include in your script. There is no sample template to provide to you. (Utilize chapter 6 of your Schuiling textbook to provide guidance). You are the one to develop the script. Think of it as you are writing a movie and you need to write the script for the movie. What lines would you provide for the actor to utilize when sitting down with a patient to perform a COMPLETE Medical History which also entails those DIFFICULT GYN questions. You do not need to provide the answers to the questions however, if you find that beneficial, you may do so. Assignment: (1- to 2-page reflection) In addition to your script for building a health history for this assignment, include a separate section called “Reflection” that includes the following: A brief summary of your experiences in developing and implementing your script during your health history. Explanations of what you might find difficult when asking these questions. What you found insightful and what would you say or do differently. Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm)Building a Health History Assignment Paper.
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All papers submitted must use this formatting. Describe the components of a comprehensive gynecologic complete health history. Include considerations for special populations such as LGBTQ+ individuals. What health maintenance guidelines should be included during the initial and follow up assessments. (i.e., bone density test, Gardasil vaccine, shingles, etc.)? What questions would you consider in your patient’s assessment?– Excellent 27 (27%) – 30 (30%) Good 24 (24%) – 26 (26%) Fair 21 (21%) – 23 (23%) Poor 0 (0%) – 20 (20%) Building a Health History: Asking Difficult Questions Create your own script for building a health history. Consider the type of language you would use to help your patient be more comfortable). Ensure you include the difficult questions required to complete a thorough health history.– Excellent 22.5 (22.5%) – 25 (25%) Good 20 (20%) – 22 (22%) Fair 17.5 (17.5%) – 19.5 (19.5%) Poor 0 (0%) – 17 (17%) In addition to your script for building a health history for this assignment, include a separate section called “Reflection” Briefly reflect and provide a summary of your experiences in developing your script during your health history.– Excellent 27 (27%) – 30 (30%) Good 24 (24%) – 26 (26%) Fair 21 (21%) – 23 (23%) Poor 0 (0%) – 20 (20%) Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.– Excellent 5 (5%) – 5 (5%) Good 4 (4%) – 4 (4%) Fair 3.5 (3.5%) – 3.5 (3.5%) Poor 0 (0%) – 3 (3%) Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation– Excellent 5 (5%) – 5 (5%) Good 4 (4%) – 4 (4%) Fair 3.5 (3.5%) – 3.5 (3.5%) Poor 0 (0%) – 3 (3%) Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.– Excellent 5 (5%) – 5 (5%) Good 4 (4%) – 4 (4%) Fair 3.5 (3.5%) – 3.5 (3.5%) Poor 0 (0%) – 3 (3%) Building a Health History Assignment Paper