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.
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.
Case C 38-year-old Native American pregnant female living on a reservation
· 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.
By Day of Week 1
1-Post a Summary of the Interview and a Description of the Communication techniques you would use with your assigned patient.
“Case C 38-year-old Native American pregnant female living on a reservation”
2-Explain Why you would use these techniques.
3-Identify the risk Assessment Instrument you selected and Justify Why it would be applicable to the selected patient.
4-Provide at Least Five targeted questions you would ask the patient.
EXPERT ANSWER AND EXPLATION
Building a Health History
Summary of the Interview with the Patient
During the interview, the 38-year-old Native American pregnant female did not show any signs and symptoms of depression, and she even stated that her adjustment to pregnancy was reasonable. In the interview process, the patient indicated that her body mass index (BMI) before pregnancy was greater than 28, suggesting that she had healthy weight gain before pregnancy. The patient also said that the pregnancy was her third time, and she has never had any miscarriage, early infant birth or stillbirth before. Moreover, the patient has never had any history of gestational diabetes, hypertension, postpartum or depression in her last pregnancy. Lastly, she has not experienced any health complications or conditions not associated with her pregnancy in three months.
Description of the Communication Techniques
The communication practices I would utilize with the patient in the case assigned are two. The techniques include asking of open-ended questions and seeking first to understand (Aryani, 2018). First, asking open questions technique involves questions which the patient cannot answer with no or yes response. Aryani (2018) explains that the method helps the interviewer to get into the head of the interviewee and guide him or her to reveal his or her desires during the interview. Second, seeking first to understand technique describes the significance of truly understanding what an individual is communicating to another person (Riley & Furst-Holloway, 2019). Thus, understanding other people need aid interviews to respond effectively and in a way that builds trust and reciprocity in the interview.
Reasons for Using the Two Techniques
Asking open-ended questions is a useful technique that will enable me to provide value to the patient and work with her successfully. The method can lead to the building of trust and making by making the interview effective and allowing the patient to express herself (Riley & Furst-Holloway, 2019). Additionally, the primary reason why I will prefer to use seeking first to understand communication technique allows people to open their hearts and mind when addressing their health problems. Thus, allowing me to get the information faster and with no struggle, enabling me to make the patient feel great during the interview.
Risk Assessment Instrument and Justification of its Applicability to the Patient
EMR Risk Assessment Tool will help to reduce the patient’s maternal death and injury that the patient may experience during childbirth (Wesson, Lucey & Cooper, 2019). Bastain et al. (2019) add that the tool has benefits to the patient because it can generate new orders that facilitate caregivers to respond swiftly to unexpected risks during pregnancies. Therefore, the instrument applies to the patient in the case study due to its distinctive advantage.
Five Questions that I would Ask a 38 year-old-Native American Pregnant Female
The questions I would ask the patient to understand better and help me to support her during her pregnancy stated below.
- How is the pregnancy going with you? What is your feeling?
- How are you feeling regarding being pregnant?
- Is this the right timing for your pregnancy?
- What was your weight before the pregnancy?
- Is the pregnancy your first one?
- How many times have you been pregnant?
- Have any of the pregnancies been miscarriage, early infant death or stillbirth?
- Did you have hypertension, gestational diabetes, postpartum or depression during your last pregnancy?
- Have you experience any health complications or conditions not associated with your pregnancy?
- When last, did you take alcoholic drinks?
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