NURS 6512 Discussion: Building a Health History
This discussion focuses on effective patient communication and the importance of it when building a health history. A healthcare provider’s ability to communicate well with a patient is crucial for obtaining accurate information. In this discussion, I will also identify a suitable risk assessment tool for the assigned patient and provide five specific questions to ask this patient.
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Summary of the Interview
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The patient in question is a 38-year-old Native American pregnant woman living on a reservation. As an Advanced Practice Registered Nurse (APRN), it’s essential to consider factors like the patient’s gender, age, ethnicity, and environment when gathering a comprehensive health history (Ball et al., 2019). Recognizing that I, as a male practitioner, cannot fully understand the pregnant woman’s experience, my approach will be rooted in compassion. I’ll explore various aspects, including medical history, procedures, substance use (like drugs, tobacco, and alcohol), prenatal care, past and current medications, sexual practices, home life, nutritional intake, and any resources they might need to manage their healthcare effectively. I’ll also ensure a comfortable and silent space for the patient to express concerns, ask questions, and provide information.
Description of Communication Techniques
Effective communication involves a clear understanding of information shared between parties (Bramhall, 2014). Communication techniques can significantly impact a patient’s treatment. Identifying potential barriers is crucial in creating a successful dialogue. Medical assessments can sometimes be uncomfortable for patients, and they may have complex feelings. Patients may become frustrated or anxious, seeking understanding and empathy from their healthcare provider. To address this, I will position myself at eye level with the patient, actively listen, speak softly, and take notes thoughtfully. I’ve noticed that using devices or taking notes during an assessment can create a disconnect with the patient, hindering the flow of information. In fact, poor communication has been linked to serious medical errors during patient transfers (Commission, 2019). I will employ the teach-back method to ensure that the patient comprehends the information.
Reasoning for Utilizing These Techniques
I plan to use these techniques to establish a genuine connection with the patient. I believe every patient deserves to be seen, heard, and understood. When patients feel acknowledged and safe, they become more open to communication. This connection and rapport are vital for creating effective treatment plans, ensuring patient safety, and maintaining continuity of care.
Risk Assessment Instrument and Its Applicability
I will use the PRAMS (Pregnancy Risk Assessment Monitoring System) tool, which is designed to assess risks for both the patient and her baby. I find this resource valuable because it not only serves as a survey but also allows for adjustments in healthcare and improves patient outcomes. PRAMS addresses several critical aspects of pregnancy, such as preconception health, folic acid awareness, HIV testing, employment, childcare, chronic conditions, stressful life events, and physical activity (Shulman, 2006). This tool is highly applicable to our patient, given her pregnancy. The questions it poses are essential and can benefit pregnant patients across the board. Early intervention can make a significant difference in achieving the best possible outcomes.
Five Targeted Questions for the Patient
1. What brings you to our healthcare facility today? I will ask this question in a way that encourages the patient to share multiple reasons for her visit, ensuring she feels comfortable and open to communication. This allows me to address all her concerns effectively.
2. Do you have any prior medical conditions or diagnoses? Is there a family history of any diseases or medical issues?
3. Can you tell me about the medications you are currently taking? Have you recently stopped any medications? I will also verify this information by cross-referencing a pharmaceutical database.
4. Do you have any allergies, whether to food, medications, or other substances? If you do, could you describe what happens when you have an allergic reaction? For instance, some individuals consider stomachaches after taking medicine as an allergic reaction, so I will seek clarity.
5. Before we conclude this assessment, is there anything else you would like to share or ask me? I believe open-ended questions can provide essential information that might not be covered otherwise.
In conclusion, my approach as an APRN involves compassionate assessment, consideration of the patient’s communication abilities, the use of reliable tools when necessary, and asking targeted questions to gather vital information for the best possible patient outcomes.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO
Bramhall, Elaine. Nursing Standard (2014+); London Vol. 29, Iss. 14, (Dec 3, 2014): 53. DOI:10.7748/ns.29.14.53. e9355
The Joint Commission, Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications, August 2012, Volume 32, Issue 8, 2019.
Shulman HB, Gilbert BC, Lansky A. The Pregnancy Risk Assessment Monitoring System (PRAMS): Current Methods and Evaluation of 2001 Response Rates. Public Health Reports. 2006;121(1):74-83.
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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
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.
Sample Response 1:
Thank you, xxx, for your insightful post. I found your approach compassionate and professional. You’ve highlighted the importance of understanding cultural diversity, which is crucial in healthcare (Goodkind et al., 2011). Native American individuals have often faced distrust from those who impose their values and beliefs on them, including healthcare providers and researchers.
In this specific case, it would be beneficial to inquire about holistic or herbal medicinal practices the patient may use. Herbal remedies have become a preferred choice for many households in the United States as people prioritize their health (Illamola et al., 2020). Various cultures have relied on herbal medicine during pregnancy to enhance the well-being of the mother and baby, alleviate issues like nausea and vomiting, and prepare for labor. This preference stems from the belief that herbal medicine is safer than conventional treatments.
Sample Response 2:
Hello xxx, your post was very informative, and I appreciate your insights. You’re absolutely right about the importance of clear communication in healthcare. Poor communication can lead to unsatisfactory patient outcomes and even medical errors (Stewart & Snowden, 2021). Ensuring that patients understand their instructions and treatment plans is vital. It’s worth noting that evaluating patient understanding by having them demonstrate or verbalize what they’ve learned can be an effective way to confirm that they have the right information.
During patient interviews, establishing rapport, accepting emotional responses without criticism, and refraining from interrupting the patient are key elements (Luizzo, 2019). Good rapport can encourage patients to open up, and avoiding interruptions ensures they don’t forget what they were about to share.
Sample Response 3:
Thank you for underscoring the importance of effective communication in obtaining accurate patient information and history. Communication skills like active listening, maintaining eye contact, and using open-ended questions are essential for healthcare providers (Arsith, 2017). These skills not only help in gathering information but also in building strong patient relationships, which are crucial for developing effective care plans (Ball et al., 2019).
References:
– Goodkind, J. R., Ross-Toledo, K., John, S., Hall, J., Ross, L., Freeland, L., … & Lee, C. (2011). Rebuilding trust: A community, multiagency, state, and university partnership to improve behavioral health care for American Indian youth, their families, and communities. Journal of Community Psychology, 39(4), 452–477.
– Illamola, S. M., Amaeze, O. U., Krepkova, L. V., Birnbaum, A. K., Karanam, A., Job, K. M., … & Enioutina, E. Y. (2020). Use of herbal medicine by pregnant women: What physicians need to know. Frontiers in Pharmacology, 10.
– Stewart, J., & Snowden, V. (2021). Promoting Communication and Safety Through Clear and Concise Discharge Orders. Journal for Nurse Practitioners, 17(7), 874–878.
– Luizzo, A. (2019). Effective interview techniques. Journal of Healthcare Protection Management, 35(2), 110–117.
– Arsith, M., & Popa, D. (2017). General aspects on the communication between healthcare provider and patient. Acta Universitatis Danubius. Communicatio, 11(1), 83–90.
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