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Discussion: 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.

To prepare:

Read a selection of your colleagues’ responses.

By Day 6 of Week 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.

· Suggest additional health-related risks that might be considered.

· Validate an idea with your own experience and additional research.

Colleague 1

Case study

The patient I will be gathering a health history from is a 14-year-old biracial male living with his grandmother in a high-density public housing complex

Communication and Interview Techniques

My communication and interview techniques for building a health history would differ with each patient based on age, ethnicity, socioeconomic background, and gender. Communicating with an elderly patient would include speaking slow and clear while looking directly at the patient to allow lip-reading if necessary and sitting close if they are hard of hearing. When communicating with a child getting down on their level to initiate play can help build trust while using age-appropriate words they can easily understand (Ball et al., 2019). When choosing interview techniques, it is essential to consider ethnicity because some cultures could find eye contact or physical touch offensive. Language barriers may also be present, so it is imperative to have the proper translation tools.

Assessing a patient’s socioeconomic background is vital during communication to ensure you speak to them on a level they understand and not be intimidating. Consider factors that may inhibit patients from low socioeconomic backgrounds from complying with their care plan. Gender should not be assumed. It is crucial to know how the patient identifies and their preferences regarding pronoun use and sexuality (Ball et al., 2019). Building trust with patients should be the first step when gathering a health history to allow the patient to be truthful and forthcoming, especially with sensitive information (Diamond-Fox, 2021).

The patient I will be gathering a health history from is a 14-year-old biracial male living with his grandmother in a high-density public housing complex. When gathering information from adolescents, it is essential to allow them to speak with you without an adult present to give them privacy. The information shared should be kept confidential unless it involves the patient’s or others’ safety (Ball et al., 2019). If the parent is present, address the patient directly, rather than directing questions towards the parent. Please do not be pushy with questions or force the adolescent to talk because they do not respond well to confrontation. It may be helpful to administer a questionnaire before the visit, so the adolescent feels more comfortable sharing information through a written format, allowing for an easier transition to verbal communication (Ball et al., 2019).

Social Determinants of Health

I would target my questions for building a health history based on the patient’s social determinants of health by speaking on an educational level that the patient can understand, identifying factors that inhibit the patient from living a healthy lifestyle, and assessing for risk factors for adverse health-related outcomes (Lastrucci et al., 2019). I would address the patient’s housing and schooling and ask if they feel safe in both environments, especially regarding bullying or racism due to their biracial background. Nutrition is also vital for a growing child of this age, so it would be essential to ask questions about their food intake (U.S. Department of Health and Human Services, n.d.).

Risk Assessment Instrument

A risk assessment instrument appropriate to use with this patient would be HEEADSSS. The HEEADSS assessment tool is a great way to address factors that specifically affect adolescents and identify risky behaviors that require intervention. Adolescence is a challenging time where one’s body changes and peer pressures are present while trying to create an identity (Smith & McGuinness, 2017). Using the HEEADSS assessment allows providers to assess the patient’s social, physical, and emotional health. HEEADSS is an acronym that stands for home, education and employment, eating, activities, drugs and alcohol, sexuality, suicide and depression, and safety from injury and violence (Smith & McGuinness, 2017). Each category will allow the provider to ask the patient questions, which can be elaborated on if necessary. Adolescents partake in numerous risky behaviors such as smoking, drinking alcohol, drugs, sex, and self-harm, making a psychosocial assessment such as HEEADSS valuable.

Targeted Questions

The following are examples of targeted questions I would ask when interviewing my patient:

Do you feel safe at home and school?

Have you ever smoked, drank alcohol, or tried drugs?

What types of food do you usually eat?

Whom do you live with?

Have you ever had sex?

I found these questions necessary to ask my adolescent patient because he is biracial living in public housing. I want to evaluate if he is experiencing any forms of racism or bullying that may cause him to be depressed and develop thoughts of self-harm or harm to others. Since this patient is from a low socioeconomic background, I want to make sure he is getting the proper nutrition and, if necessary, offer resources. Adolescence is when experimenting with smoking, alcohol, drugs, and sex occurs, leading to adverse long-term effects. If my patient does partake in any of these activities, I must provide education on the consequences of these actions and available resources. When asking the patient whom he lives with, I can identify why his parents are not in the home and if there is trauma present from the lack of a nuclear family unit.

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