NURS 6512 BUILDING A HEALTH HISTORY

Walden University NURS 6512 BUILDING A HEALTH HISTORY– Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6512 BUILDING A HEALTH HISTORY assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6512 BUILDING A HEALTH HISTORY

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 BUILDING A HEALTH HISTORY depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6512 BUILDING A HEALTH HISTORY

The introduction for the Walden University NURS 6512 BUILDING A HEALTH HISTORY is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6512 BUILDING A HEALTH HISTORY

After the introduction, move into the main part of the NURS 6512 BUILDING A HEALTH HISTORY assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6512 BUILDING A HEALTH HISTORY

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6512 BUILDING A HEALTH HISTORY

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS 6512 BUILDING A HEALTH HISTORY

The case scenario for the NURS 6512 BUILDING A HEALTH HISTORY discussion concerns a 35-year-old white male with a history of morbid obesity with disabilities living in a rural setting. In this case, I will ask the patient about his current chief complaints or the reason for seeking medical care. In this regard, I will inquire about the onset of symptoms, location, characteristics, alleviating and exacerbating factors, and severity. In addition, I will ask about symptoms related to complications of obesity, like sleep apnea, easy fatigue, exertional dyspnea, and high respiratory rate. Furthermore, I will examine the NURS 6512 BUILDING A HEALTH HISTORY discussion’s patient’s medical and surgical history, family medical history, and social/lifestyle history, including his living status, source of income, primary caregiver, hobbies, dietary habits, sleeping patterns, and physical activity patterns.  

Communication Techniques  

Effective communication techniques are vital in creating a successful provider-patient relationship. Communication techniques that I would apply when interviewing the patient include addressing him in the proper form. I would ask the patient how he wishes to be addressed or call him Mr. to foster respect. Besides, I would greet the patient, introduce myself, and demonstrate that I am interested in understanding his health concerns to create a rapport (Butt, 2021). In addition, I will tailor the communication as per the patient’s disability. Thus, I will vocalize my communication and avoid high tones if he has a visual impairment. Besides, if he has a hearing impairment, I will use a sign translator and speak slowly to allow him to read my lips (Agaronnik et al., 2019). Furthermore, I would ensure the assessment room is quiet and free from human interruptions to ensure the patient is comfortable and assure him of the privacy and confidentiality of his health information. Active listening would also be employed by using frequent, brief responses and maintaining eye contact. This is crucial in maintaining the NURS 6512 BUILDING A HEALTH HISTORY discussion patient’s focus in the interview and making him aware that his concerns are being considered. 

Risk Assessment Instrument for NURS 6512 BUILDING A HEALTH HISTORY

Abuse Assessment Screen–Disability (AAS-D) is the identified risk assessment instrument most suitable for this patient. AAS-D was created and tested to address the range of abuse faced by persons with physical disabilities. The patient is vulnerable to abuse due to his disability since he depends on others to carry out various activities of daily living (Meyer et al., 2020). Disability-related abuse is attributed similarly to an intimate partner, a care provider, or a healthcare provider. Besides, neglect and abandonment are specific to abuse of disabled persons since they are perceived as a burden by family members and caregivers. Therefore, AAS-D is appropriate for this patient to examine his risk of physical, emotional, financial, and sexual abuse from his family members, care providers, and strangers (Lund, 2020). The results can help in reporting abuse to the relevant authorities and put the patient in a setting free from disability-related abuse. 

Targeted Questions 

1. How has your history of obesity affected your overall health and functioning? 

2. What limitations do you often experience in occupational and social functioning due to disability? 

3. What activities of daily living do you often require assistance in performing? 

4. Who is your primary caregiver at home? 

5. How often do you get the help you need in performing daily living activities? 

6. How has obesity affected your self-image and esteem? 

Also Read:

DIVERSITY AND HEALTH ASSESSMENTS

CASE STUDY ASSIGNMENT: ASSESSMENT OF NUTRITION IN CHILDREN

DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT

LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT

DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH

LAB ASSIGNMENT: ASSESSING THE ABDOMEN

DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

ASSESSING MUSCULOSKELETAL PAIN

CASE STUDY ASSIGNMENT: ASSESSING NEUROLOGICAL SYMPTOMS

DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM

References 

Agaronnik, N., Campbell, E. G., Ressalam, J., & Iezzoni, L. I. (2019). Communicating with Patients with Disability: Perspectives of Practicing Physicians. Journal of general internal medicine, 34(7), 1139–1145. https://doi.org/10.1007/s11606-019-04911-0 

Butt, M. F. (2021). Approaches to building rapport with patients. Clinical medicine (London, England), 21(6), e662–e663. https://doi.org/10.7861/clinmed.2021-0264 

Lund, E. M. (2020). Interpersonal violence against people with disabilities: Additional concerns and considerations in the COVID-19 pandemic. Rehabilitation Psychology, 65(3), 199–205. https://doi.org/10.1037/rep0000347 

Meyer, S. R., Lasater, M. E., Lee, L., & Garcia-Moreno, C. (2020). Measurement of violence against women and disability: protocol for a scoping review. BMJ Open, 10(12), e040104. https://doi.org/10.1136/bmjopen-2020-040104 

Sample Answer 2 for NURS 6512 BUILDING A HEALTH HISTORY

I am working with A 16-year-old girl living in an inner-city neighborhood.  It’s no secret working with teenagers can be difficult.  As her nurse, I would introduce myself and explain my reasoning for talking with her.  Starting with honest and open discussion is an excellent way to establish a trusting relationship with this age group. “Adolescence is an important period during which risky behaviors and mental health concerns often develop, contributing to adolescent morbidity and mortality and increasing the risk of developing lifelong chronic conditions (Thompson, Wegman, Muller, Eddelton, et al., 2016)”.  This age group is not big on sharing with adults and tends not to want to talk about personal problems.  I would ask open-ended questions to avoid yes or no answers.    

 I would make sure the room is a quiet, well-lit environment.  I would ask any family members to step outside to provide privacy.  I will explain to my patient that everything that she discusses with me will be confidential.  “When you find a GP you and your child feel comfortable with, you can get to know each other and talk openly (Raising Children, n.d.)”.  Teens growing up in the inner city need to establish that trust to start and open communication.  
 
Risk Assessment Tools: 

Provider-initiated health risk assessment (HRA) screening and counseling 

Adolescent Risk Assessment 

Social Mental Health Assessment Tool 

Violence Risk Assessment Tool 

Bright futures tool 
 
The tool I choose is the Adolescent Risk Assessment Tool, “Using a screening tool allows risky behaviors to be reviewed before talking with teens so that the provider can gather resources. It can help start the conversation, and, while still screening for multiple risks, allows the discussion and counseling to focus on the issues most affecting that teen (UMHS, 2016)”.   This tool will help me better understand my patient and narrow down her needs.   

 
1. How is your diet at home?  Do you eat three meals a day? Are vegetables incorporated into your diet?   

2. How often do you drink water or sodas? How often do you eat sweets?  

3. How many hours a day do you spend online?  Do you spend much time having a face-to-face conversation with others? 

4. Do you have a regular menstrual cycle?  Do you have painful menstrual cycles? If so, how often do you miss school due to painful cycles?  

5. How well do you know your family health history? Any history of cardiac disease, diabetes, obesity, cancer? 

 
I choose this risk assessment tool because it touches many areas such as daily lifestyle, health risks, and benefits and provides a way for the teen to develop open communication with her parents.   

 
References 

 
Raising Children.  (n.d.). Mental health professionals for teenagers: a guide. Retrieved from https://raisingchildren.net.au/pre-teens/mental-health-physical-health/mental-health-therapies-services/mental-health-professionals-for-teens 
 
Thompson, L. A., Wegman, M., Muller, K., Eddleton, K. Z., Muszynski, M., Rathore, M., De Leon, J., Shenkman, E. A., & Health IMPACTS for Florida Network (2016). Improving Adolescent Health Risk Assessment: A Multi-method Pilot Study. Maternal and child health journal, 20(12), 2483–2493. https://doi.org/10.1007/s10995-016-2070-5 
 
UMHS. (2016). Adolescent Risk Screening. Retrieved from https://www.umhs-adolescenthealth.org/wp-content/uploads/2017/02/adolescent-risk-screening.pdf 

Sample Answer 3 for NURS 6512 BUILDING A HEALTH HISTORY

History of 76-year-old black male with disabilities living in an urban setting.  

The first task during this patient encounter is to obtain a comprehensive history and physical examination (if possible). This can be prolonged due to the fact that the patient is elderly and is with disabilities.  Obtaining a comprehensive history from this patient is very important because according to Ghosh & Karunaratne (2015), “early comprehensive geriatric assessment (CGA) with good history-taking is essential in assessing the older adult”. Therefore, the first task is to employ appropriate method to obtain detailed history and physical examination of this patient.  

Description of communication and interview techniques 

            Obtaining a comprehensive medical history of elderly with disabilities can be very challenging especially if additional documentation and third parties need to be involved. Therefore I will employ patient-centered interview technique during the patient encounter to obtain necessary information from this elderly patient. Just like any other patient encounter, the first step is to make a very good impression on the patient by showing courtesy and professionalism throughout the encounter. I will show courtesy by knocking at the door before entering the room while I dress professionally with correct grooming and hygiene. I will then proceed to greet the patient and any other significant others in the room (if any), introduce myself properly with my (last name and title), and then establish patient’s preferred title and clarified my role. Depending on the situation, I will allow the patient time to be dressed and comfortably settled before and after the history with assurance of confidentially. I will ensure that the patient is comfortable throughout the encounter and remind him regularly to notify me if he feels any discomfort at any time during the history taken.  

Once the patient is comfortable enough to answer my question, I will proceed to ask for the patient name and how he would like to be addressed. Some of the questions that I will asked the patient include but not limited to the following: 

How he is feeling today?, what he think is causing your symptoms and what is his understanding of his disabilities/diagnosis? How does he feel about his illness and the treatment? How is he coping with his disabilities and the level of help he is receiving? I will also asked him if he has prepare any advance directives and who can be contacted for more information or support about his illness or hospitalization? Family members?, Friends?, Employer? Religious advisor? Attorney? I will also ask about his financial situation and how is paying for his medical care? Insurance coverage or Medicaid? Tests or treatment he may not be able to afford? Timing of payments required from him? 

Throughout the encounter, I will try to maintain eye contact and use of open ended question while discussing with the patient. Finally, I will request a confirmation from the patient that he understood me clearly and ask him to ask any question that may be bothering him about his health or disabilities. 

Risk Assessment instrument – Functional Assessment and Physical Disabilities 

In order to assess the extent of disability of the patient, I will ask direct question on how patient handle fundamental skills such that constitute Activities of daily living (ADLs. Such activities include the  following areas: grooming/personal hygiene, dressing, toileting/continence, transferring/ambulating, and eating. Patient’s response to question of (ADLs) will guide on how to help the patient to cope with his present disabilities. According to Mlinac and Feng (2016), ADLs skills are usually mastered early in life and are relatively more preserved in light of declined cognitive functioning when compared to higher level tasks. 

Finally, the extent of physical disability of the patient will be assessed. This will include the extent of mobility that can be tolerated without unbearable discomfort. This will include walking distance and range of motion in all limbs. This is very important in evaluating the patient’s independence and autonomy. It will also show the extent of his reliance on other people or assistive devices. Based on patient’s responses, result of the test and the level of social support system that that patient currently enjoys, a comprehensive management plan can be developed for proper care of the patient.   

References 

Ghosh, D., & Karunaratne, P. (2015). The importance of good history taking: a case report. Journal of medical case reports, 9, 97. https://doi.org/10.1186/s13256-015-0559-y 

Mlinac, M. E., & Feng, M. C. (2016). Assessment of Activities of Daily Living, Self-Care, and Independence. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists, 31(6), 506–516. https://doi.org/10.1093/arclin/acw049 

Ohm, F., Vogel, D., Sehner, S., Wijnen-Meijer, M., & Harendza, S. (2013). Details acquired from medical history and patients’ experience of empathy–two sides of the same coin. BMC medical education, 13, 67. https://doi.org/10.1186/1472-6920-13-67 

Sample Answer 4 for NURS 6512 BUILDING A HEALTH HISTORY

K.Vail Initial post: 16 year old white female who lives in the inner city  

      A nurse practitioner student formulates a health history interview to begin building a relationship with the patient. This process helps both patient and provider figure out problems that are the top priority for an encounter (Jane W. Ball, 2019). Developing a health history is a multi-step approach that starts with appropriate introductions of both patient and provider. In this case, the provider would be this nurse practitioner student. While introducing oneself, ensure that proper identification of the patient is done and address how they would like to be addressed (Jane W. Ball, 2019). Be sure to remove distractions from the room and minimize obstacles between the NP student and the patient. Minimizing obstacles and distractions will help the patient feel comfortable and open communication between NP student and patient. The NP student will speak with the patient about why they are seeking medical care at this time. Ensure that the patient accurately clarifies the purpose of seeking treatment and their expectations for the visit/encounter (Jane W. Ball, 2019). The NP student should actively listen and seek clarification when appropriate. Clarification can be done through open-ended questions about where the symptoms are located, what makes them worse, address when they started. A precise timeline and specifics of these events will assist in formulating a pattern to the illness. It is helpful for the NP student to use a where, when, what, how, and why approach for clarifying the illness’s events (Jane W. Ball, 2019). This format will aid in obtaining as much useful information as possible. Once there is a clear purpose to the patient’s expectation and primary problem, health history should be obtained. The health history will include underlying medical problems, family, socioeconomic, psychosocial, emotional, and workplace conflicts (Jane W. Ball, 2019). The final step in the health history is for the provider to summarize the situation. Summarizing ensures that the goals that are put forth are appropriate and agreed upon between NP student and patient. By reviewing the information, it may help the patient (Jane W. Ball, 2019). Patients may struggle to convey some elements of their illness to the provider. Various factors affect the patient’s expression of the disease. The body presents with a disease in the form of an illness, and this process is multifactorial (Jane W. Ball, 2019). Due to all of these above factors and age, ethnicity, geographical location, socioeconomic status, religion, values, and resources available, health care history may differ between all patients. No one will be the same. By asking specific open-ended questions and spending time formulating the health history interview, the NP student will better understand the patient and their problems. 

           The basis of assessing the health history is similar between age groups. However, there can be variations related to age and developmental understanding. This particular scenario relates to a 16-year-old white female living in the inner city. The patient is in an age range that automatically places her at increased risk for injury due to their inherent risk-taking behaviors (Jane W. Ball, 2019).  

According to the Journal of American Medical Association, “eight million persons age 12 years or greater met diagnostic criteria for drug abuse or dependence (US Preventive Services Task Force, 2020)”, and in 2017 seventy thousand fatal overdoses occurred (US Preventive Services Task Force, 2020). When evaluating and communicating with an adolescent, ensure privacy and confidentiality. The pre-visit questionnaire is named in the literature as it helps adolescents communicate more efficiently and effectively (Jane W. Ball, 2019).  

JAMA states that there is little to no evidence that states that risk behaviors can be effectively evaluated through adolescents’ screening tools (US Preventive Services Task Force, 2020). However, it is stated that they do not harm the patient to be utilized (US Preventive Services Task Force, 2020). One screening tool that is commonly used is the CRAFFT screening tool. This tool is used to evaluate alcohol use in adolescents. CRAFFT stands for car, relax, alone, forget, friends, and trouble (US Preventive Services Task Force, 2020). An alternative assessment tool that may help evaluate this patient may be the Health-Related Quality of Life assessment tool. Health-Related Quality of Life assessment is also known as the HRQOL. The HRQUL tool is used to evaluate physical and social functioning, mental health, and well-being. Studies suggest that the HRQOL tool may show favorable patient outcomes when adolescents have healthy lifestyles (Xiu Yun Wu, 2017). During a health history assessment, it is also recommended to address safety at home and in relationships with patients of all ages, especially those in high-risk groups. High risk for abuse groups would include minorities, children, the elderly, sick, and females (Jane W. Ball, 2019).  

The health history assessment will also assist in determining if the patient has a chronic medical condition. Combining the patient being chronically ill and this particular age group drastically increases the child’s risk for risky behaviors (Derrick Ssewanyana, 2017). Specific behaviors to monitor for would be the use of alcohol, tobacco, drugs, and inactivity (Derrick Ssewanyana, 2017). This is important because patients who are chronically ill and partake in high-risk behaviors risk treatment regimens being disrupted, leading to suboptimal results (Derrick Ssewanyana, 2017). 

           Target questions to be asked during the health history could be, “what brings you here today?” or “how are you feeling today?”. These two questions would address why the patient is here and initiate the conversation of the primary complaint. The patient could be evaluated with the CRAFFT assessment by oral or written formats. The questions would be similar to this: 

Part A would ask the patient if they drink alcohol, use marijuana, synthetic marijuana, and THC oil, and do they use anything else to get high (John R. Knight, 2016) 

1.  ”have you ridden in a car driven by someone or have you driven a vehicle high or while using drugs or alcohol?”  

         2. “Do you use alcohol or drugs to relax or feel better about yourself. Have you ever tried drugs to help you fit in?” 

           3. “Do you use alcohol or drugs while you are alone?” 

    drinking “Do you ever forget things that you did while using drugs or alcohol?” 

          5. “have your family or friends ever told you that you should cut down on your drinking of alcohol or use of drugs?” 

          6. “Have you ever gotten into trouble while you were using alcohol or drugs?” 

These questions, when asked, will be allotted a single point. If the patient scores a two or better, there is potential for a significant problem, and further evaluation is required (John R. Knight, 2016). 

In conclusion, when speaking with adolescents, consent needs to be addressed with the person who is legally responsible for them before evaluation can begin. Specific care must be taken when speaking to this 16-year-old girl to ensure privacy and confidentiality. Adolescents are at the highest risk for injury related to high-risk behaviors that they have. That is why screening tools may be helpful to evaluate patient needs during the health history assessment. Screening tools do not diagnose problems, and no substantial evidence says that they help identify this particular age group’s problems. They are used for aids to identify if patients are at risk for a problem so the provider can assist in setting up further resources for assistance.  

Resources 

Derrick Ssewanyana, M. K. (2017, July 17). Health risk behavior among chronically ill adolescents: a systematic review of assessment tools. Child and Adolescent Psychiatry and Mental Health , 1-18. 

Jane W. Ball, J. E. (2019). Seidel’s Guide to Physical Examination An Inter professional Approach. St. Louis, MO: Elsevier. 

John R. Knight, M. (2016, na na). Center for Adolescent Substance Abuse Research. Retrieved from the CRAFFT Questionnaire (Version 2.1): https://njaap.org/wp-content/uploads/2018/03/COMBINED-CRAFFT-2.1-Self-Admin_Clinician-Interview_Risk-Assess-Guide.pdf 

US Preventive Services Task Force. (2020, June 9). Screening for unhealthy drug use: US preventive services task force recommendation statement. JAMA Network , NA. 

Xiu Yun Wu, L. H. (2017). The influence of physical activity, sedentary behavior on health-related quality of life among the general population of children and adolescents: A systematic review. Pone Journal China , na. 

Sample Answer 5 for NURS 6512 BUILDING A HEALTH HISTORY

Accurate patient history is essential for APRNs to develop appropriate care plans and comprehensively understand their previous health concerns (Ding et al., 2020). The provided case study presents a 33-year-old Caucasian individual who identifies as male despite being assigned female at birth. Three years ago, the individual transitioned from female to male while residing in Florida. Now, he has returned to his home in Texas and is openly sharing his complete transition with his family and social circle. He is currently without employment and lacks access to further hormonal replacement for suppression. The individual has a documented history of depression, is living with HIV, and engages in the use of cannabis. The paper demonstrates my role as the APRN in communicating effectively and building the patient’s health history described above.

Socioeconomic, Spiritual, Lifestyle, and other Cultural Factors

The various factors related to a patient’s socioeconomic status, spirituality, lifestyle, and culture can significantly affect their access to healthcare, financial burdens, and decision-making processes. B.C. is currently without employment and lacks access to further hormonal replacement for suppression. Unemployment can impact individuals’ access to healthcare and ability to afford necessary medications or treatments. Transitioning may also incur financial expenses (Sbragia & Vottero, 2020). In addition to his medical history, he has a diagnosis of depression, is living with HIV, and uses cannabis. The patient’s spiritual beliefs can impact their coping mechanisms, support systems, and decision-making regarding healthcare. Individuals who are HIV positive and engage in cannabis consumption may experience effects on their overall well-being, necessitating the need for proper care and assistance. Transitioning from female to male, particularly in conservative regions such as Texas, can pose difficulties concerning acceptance, discrimination, and the availability of transgender-affirming healthcare (Friley & Venetis, 2021).

Sensitive Issues

As an APRN, it is crucial to recognize the significance of respectful interactions with B.C. This includes honoring his gender identity, acknowledging his journey, maintaining a non-judgmental attitude towards his HIV status and cannabis use, respecting his privacy and confidentiality, and fostering a safe environment that encourages open communication. It is clear that B.C. is currently facing personal, economic, and emotional challenges, and it is crucial to address these concerns professionally. It is crucial to offer comprehensive counseling and educate patients about appropriate treatment for HIV while ensuring a stigma-free environment (Boyd et al., 2022). Addressing the sensitive issue of hormonal replacement therapy requires respectful consideration, ensuring that the patient’s dosage is appropriate. B.C. should be informed about the health risks associated with smoking marijuana and encouraged to quit. In order to prevent any potential victimization based on B.C. appearing as a male, it is essential to approach the situation professionally and ensure that he feels treated with the same level of respect as everyone else.

Communication Techniques

In order to establish effective communication with B.C., it is crucial to utilize affirming language and pronouns that correspond to the patient’s gender identity. Additionally, active listening, empathy, and allowing the patient to lead the conversation are essential. Employing open-ended questions and delivering apparent explanations further contribute to successful communication. It is crucial to employ communication techniques prioritizing respect for identity, cultural sensitivity, a non-judgmental attitude, and empathy (Kronk et al., 2021). It is essential to prioritize the patient’s autonomy by allowing them to guide the conversation, share information at their preferred speed, and employ open-ended questions to delve into their needs and objectives. As a nurse practitioner, it is crucial to communicate with patients clearly and compassionately, avoiding using complex medical terminology.

Health History Interview

As an APRN, I will proficiently do a health history interview with B.C. using active listening, open-ended inquiries, reassurance, and cooperation. Active listening entails attentively observing the patient’s reactions, asking more inquiries, and motivating them to divulge further details about their encounters. Open-ended questions promote confidentiality and foster patient engagement in decision-making processes. Here are some specific questions I would ask the patient (Mikulak et al., 2021):

1. Could you please provide a detailed account of your transition process and highlight any obstacles you encountered during this period? This inquiry recognizes the patient’s progression and offers an understanding of their encounters and requirements.
2. How are you coping with your HIV diagnosis, and are you now doing treatment? This inquiry evaluates the patient’s ability to effectively manage their HIV condition and adhere to the prescribed treatment regimen while also identifying any obstacles that may hinder their access to healthcare.
3. Could you elaborate on your use of cannabis and how often you engage in its use? Have you encountered any adverse consequences? This inquiry delves into the patient’s patterns of drug use and the possible health hazards linked to cannabis.
4. Do you have significant spiritual or cultural beliefs crucial to your health and well-being? This question acknowledges the impact of spirituality and culture on the patient’s healthcare choices and strategies for dealing with difficulties.
5. What is the specific effect of transitioning on your mental health, specifically about depression? This inquiry pertains to the patient’s psychological well-being and the possible need for assistance or intervention.

Risk Assessment

The Patient Health Questionnaire-9 (PHQ-9) is a risk assessment tool that applies to B.C. since it may evaluate symptoms of depression, track changes in mood over time, and inform treatment choices, thereby making it a significant resource for this patient’s care. The patient has a documented history of depression, is now jobless, openly communicating their complete gender change to both family and society, has tested positive for HIV, and engages in cannabis use, all of which are recognized risk factors for depression. The PHQ-9 is a very accurate and consistent instrument for diagnosing Major Depressive Disorder, with a sensitivity rate of 88% and a specificity rate of 88% (Costantini et al., 2021).

Conclusion

APRNs rely on precise patient history to formulate treatment plans and get insight into previous medical issues. Age, gender, ethnicity, and living environment influence a patient’s health. Proficient communication and interviewing strategies are crucial for acquiring information. The male patient in the given case study is transitioning from female to male. Several aspects, such as socioeconomic status, spirituality, lifestyle, and cultural background, influence this change. These factors affect the patient’s ability to access healthcare, the financial expenses involved, and the decision-making process. Effective communication requires respectful interactions, the use of affirming words, active listening, empathy, and the use of open-ended inquiries.

References

Boyd, I., Hackett, T., & Bewley, S. (2022). Care of Transgender Patients: A General practice Quality Improvement approach. Healthcare, 10(1), 121. https://doi.org/10.3390/healthcare10010121

Costantini, L., Pasquarella, C., Odone, A., Colucci, M. E., Costanza, A., Serafini, G., Aguglia, A., Murri, M. B., Brakoulias, V., Amore, M., Ghaemi, S. N., & Amerio, A. (2021). Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review. Journal of Affective Disorders, 279, 473–483. https://doi.org/10.1016/j.jad.2020.09.131

Ding, J. M., Ehrenfeld, J. M., Edmiston, E. K., Eckstrand, K., & Beach, L. B. (2020). A model for improving health care quality for transgender and gender nonconforming patients. Joint Commission Journal on Quality and Patient Safety, 46(1), 37–43. https://doi.org/10.1016/j.jcjq.2019.09.005

Friley, L. B., & Venetis, M. K. (2021). Decision-making criteria when contemplating disclosure of transgender identity to medical providers. Health Communication, 37(8), 1031–1040. https://doi.org/10.1080/10410236.2021.1885774

Kronk, C. A., Everhart, A. R., Ashley, F., Thompson, H. M., Schall, T. E., Goetz, T. G., Hiatt, L., Derrick, Z., Queen, R., Ram, A., Guthman, E. M., Danforth, O. M., Lett, E., Potter, E., Sun, D., Marshall, Z., & Karnoski, R. (2021). Transgender data collection in the electronic health record: Current concepts and issues. Journal of the American Medical Informatics Association, 29(2), 271–284. https://doi.org/10.1093/jamia/ocab136

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Sample Answer 6 for NURS 6512 BUILDING A HEALTH HISTORY

A health history is the first step of patient assessment and includes collecting subjective information on the patient’s health status. Carefully interviewing the patient is essential to obtaining most of the information. The purpose of this paper is to create a script that can be used on a first patient encounter for a well-woman appointment.

Script for Building a Health History

• Hello XX. I am XX, and I will be the nurse practitioner who will examine you today. I believe that this is your first well-woman appointment.
• The interview will take less than 20 minutes. The questions will be about your medical and sexual history, some of which might feel embarrassing.
• Do not worry about the awkward questions; they are part of our well-woman exam for all our female clients. I will be documenting what you tell me in your patient file.
• However, I assure you that your information will remain private and confidential and not be shared without your consent.
• I hope this encourages you to open up during the interview so that I can identify any issues that may require attention.

I will start by asking about your personal information.

1. What is your full name?
2. How old are you?

• Which ethnic group do you identify with?

1. What is your address?

Okay, thank you for providing the information. We will now turn to your medical history.

1. Which chronic or recurrent medical conditions do you have?
2. Have you had any surgeries?

• Are you on any prescription or over-the-counter medications or supplements?

1. Do you have any medication, food, or environmental allergies?
2. Do you remember when you last got Tetanus and Flu vaccines?

We are proceeding well with the interview. I will now ask about your social history.

• What is your education level?
• What is your current source of income?
• Do you smoke tobacco, and if yes, how many packets per day?
• Do you take alcohol, and if yes, how frequently and what amount do you take?
• Do you use any illicit substances?
• Which medical insurance do you have?
• Which physical exercises do you engage in, and how frequently?
• How many meals do you have daily, and which do you mostly take?

We will now proceed to your gynecologic health history, where I will focus on abnormal symptoms, menstruation history, contraception, reproductive history, and sexual functioning.

Reproductive medical history

• Do you have a history of abnormal vaginal bleeding?
• Have you experienced a history of abnormal vaginal discharge in the past months?
• Which of the following conditions have you ever been diagnosed with: Vaginal infections, yeast infections, pelvic inflammatory disease, endometriosis, cervicitis, fibroids, and ovarian cysts. (Hagey et al., 2020).
• Have you ever had an STI, and how was it treated?

Menstrual history

• At what age did you get your first menses?
• What is the average length of your cycle?
• What is the regularity of the cycle? (Casola et al., 2024).
• What is the average duration of menses?
• Do you experience heavy bleeding or very painful menses?
• Do you experience large blood clots during your menses? (Casola et al., 2024).
• Which type of tampons or pads do you use, and how many do you use daily?
• Do you experience spotting between menses or missed menses in some months?
• Do you experience any of these symptoms 3 to 7 days before the onset of menses: breast tenderness, bloating, moodiness, cravings, fatigue, weight gain, headaches, joint pain, nausea, or vomiting? (Casola et al., 2024).

Contraception

• Are you sexually active?
• Which type of birth control do you use, and how long have you used it?
• Which other birth control methods have you previously used, and why did you stop using them? (Aryal & Atreya, 2022)

Sexual functioning

• What is your sexual preference, i.e., are you attracted to people of the opposite or same sex? (Aryal & Atreya, 2022)
• How many sexual partners do you currently have?
• How would you rate your satisfaction with sex?
• What problems do you experience during sex?

SDOH

• What challenges do you experience accessing reproductive health services? (Hagey et al., 2020).
• Do you face discrimination when accessing sexual health services?

Thank you for your cooperation so far. We are done with the health history. Please feel free to ask any questions before we proceed to the physical exam.

Conclusion

            Building a health history includes identification information, a complete health history, concluding, and documentation. A well-woman exam should include the patient’s demographic data, medical and surgical history, social history, and gynecology history. The gynecology history should include information like reproductive history, menstruation history, contraception, reproductive history, and sexual functioning.

Reflection

            When creating the above script, I visualized taking an actual well-woman history and the questions I would ask the client. My experience working in an outpatient gynecologic exam was fundamental in helping me build the script. I have encountered instances where women have come for a well-woman exam, and I used the questions the clinician asked to create the script. I identified that a past medical history is crucial to determining the background health status of the patient, including present status, recent health conditions, and past health conditions. It was also important to help identify any change in the patient’s normal pattern of health and clues that may aid in diagnosing the present illness.

            Reflecting on this experience, I have identified that I could face challenges asking some of these questions, especially in the gynecologic health history. For instance, I imagined that if the client were a woman much older than me, I would feel uncomfortable asking if she is sexually active, uses condoms, and the number of sexual partners she has. Furthermore, it might be difficult to ask clients how they would rate their satisfaction with sex, given that most might feel embarrassed and may not be honest with their responses. It would also be awkward to ask patients about the problems they experience during sexual intercourse. I would find it insightful to inform the client that the questions are part of the normal well-woman exam and can help identify underlying gynecologic health issues. Many women face disparities in accessing reproductive and sexual health services. As an NP, I would campaign for the creation of reproductive health clinics in all healthcare settings to improve access to these services.

References

Aryal, S., & Atreya, A. (2022). History taking in gynecology revisited. Acta bio-medica : Atenei Parmensis, 92(6), e2021554. https://doi.org/10.23750/abm.v92i6.11940

Casola, A. R., Renaud, A., & Mulki, A. K. (2024). Discussing menstrual health in family medicine. Family Medicine and Community Health, 12(2), e002149. https://doi.org/10.1136/fmch-2023-002149

Hagey, J. M., Toole, J., Branford, K., Reynolds, T., Livingston, E., & Dotters-Katz, S. K. (2020). Understanding Sexual Complaints and History Taking: A Standardized Patient Case on Dyspareunia for Obstetrics and Gynecology Clerkship Students. MedEdPORTAL: The Journal of Teaching and Learning Resources, p. 16, 11001. https://doi.org/10.15766/mep_2374-8265.11001