Building a Comprehensive Health History Essay

Building a Comprehensive Health History

The patient selected to build a health history is a 38 year old Native American pregnant female living on a reservation.

Interview and Communication Techniques

I would begin the interview by introducing myself to the patient and explaining why and what we would be discussing. The patient has to confirm that they are comfortable talking to me before continuing the interview. I will use the following communication techniques;

Observation. The interviewer can learn more about the patient from their non-verbal cues such as facial expression, sitting position, and body movements (Kim & Sim, 2020).

Use of open-ended questions. It allows the patient an opportunity to share more details about their situation without leaving anything out. The patient will provide more than yes and no answers.

Listening. Patients are encouraged to be honest in an interview when they are sure that the listener is interested. Techniques such as nodding, maintaining eye contact, and taking notes show the patient that the interviewer is keen.

Risk Assessment Instrument

The risk assessment instrument chosen is the Antenatal Psychosocial Health Assessment (ALPHA) tool. The patient is 38; therefore, her pregnancy is considered high risk (Fowler et al., 2022). The ALPHA tool will give full details on her healthcare beliefs, living situations, family history, social history, and mental health status (Blackmore et al., 2006).

 

Targeted Questions

• How many pregnancies have you had?
• Do you have any children? If yes, how many?
• How far along is your pregnancy, and when was your last menstrual period?
• How were your other pregnancy and delivery experiences?
• Are you experiencing any nausea or vomiting?
• Do you have any preexisting conditions or chronic illnesses?
• Are you taking prenatal supplements such as folic acid? (Fowler et al., 2022)

 

References

Blackmore, E. R., Carroll, J., Reid, A., Biringer, A., Glazier, R. H., Midmer, D., Permaul, J. A., & Stewart, D. E. (2006). The use of the Antenatal Psychosocial Health Assessment (ALPHA) tool in detecting psychosocial risk factors for postpartum depression: a randomized controlled trial. Journal of obstetrics and gynecology Canada: JOGC = Journal d’obstetrique et gynecologie du Canada: JOGC, 28(10), 873–878. https://doi.org/10.1016/S1701-2163(16)32268-X

Fowler JR, Mahdy H, Jack BW. Pregnancy. [Updated 2021 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448166/

Kim, A. Y., & Sim, I. O. (2020). Communication Skills, Problem-Solving Ability, Understanding of Patients’ Conditions, and Nurse’s Perception of Professionalism among Clinical Nurses: A Structural Equation Model Analysis. International Journal of environmental research and public health, 17(13), 4896. https://doi.org/10.3390/ijerph17134896

 

Patient to build case on: 38-year-old Native American pregnant female living on a reservation

Please make sure that you answer all of the required info in your post:

• 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.

To 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.

By Day 3 of Week 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient.

Explain why you would use these techniques.

Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient.

Provide at least five targeted questions you would ask the patient.