NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY

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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? NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY
• 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.

Introduction

In this case study, we explore the story of an 85-year-old Caucasian woman who lives alone and faces declining health with no family support. To examine this case, I utilized the SOAP note format, which is detailed below:

Subjective (S): JD, an 85-year-old white woman, arrived at the emergency department with concerns about her declining health. This decline is linked to multiple falls and pain in her left hip. These falls began about a year ago but have worsened in the last three months. The latest fall happened today as she was getting up to use the bathroom, causing her to fall on her left side. She dialed 911 right away. She mentions that the pain in her left hip worsens when she puts weight on it, making it impossible for her to bear any weight on the left side. She hasn’t taken any pain relievers, and she describes the pain as excruciating when she tries to move or bear weight. She doesn’t use any aids for mobility. Her daily intake consists of just one meal, with an attempt to have a Boost supplemental shake daily. JD also experiences sporadic urine incontinence. Unfortunately, she doesn’t have any family or friends available to assist her, although she still drives, preferring not to drive at night.

JD has a medical history that includes osteoporosis, hypertension, dyslipidemia, anxiety, and depression. Her current medications are metoprolol tartrate 50 mg twice daily, atorvastatin 20 mg daily, sertraline 50 mg daily, a daily multivitamin, and vitamin D3 25 mcg daily.

Objective (O): JD is an elderly Caucasian woman who appears frail, undernourished, and anxious. She’s alert and oriented in all aspects. Her vital signs show blood pressure at 143/94, pulse rate at 101, respiratory rate at 20, blood oxygen saturation at 97% while resting, and a body temperature of 97.8°F. She weighs 91 pounds and stands at 5 feet 1 inch tall, resulting in a BMI of 17.2. Significant bruising is noticeable on her left lower extremity, extending from the hip’s lateral aspect towards the groin and down to just above her knee. X-rays confirm a left femoral neck fracture.

Assessment (A): 1.) Traumatic fracture of the left femoral neck 2.) Falls 3.) Malnourishment 4.) Hypertension 5.) Osteoporosis 6.) Dyslipidemia 7.) Anxiety 8.) Depression.

Plan (P): JD is to be admitted to the hospital for immediate surgery due to the traumatic left femoral neck fracture. There are plans for referral and transfer to orthopedics. The patient has received education on proper nutrition and maintaining a healthy weight through a teaching session and informational materials. The healthcare provider discussed the safety of JD continuing to live at home, and she intends to return home following her hospital stay. After discharge, JD is scheduled for follow-up with the orthopedic surgeon, primary care provider, and cardiologist. The possibility of transitioning to a skilled nursing facility was also discussed and agreed upon by the patient. Medication adjustments include the addition of hydrocodone-acetaminophen 5-325 every 4-6 hours as needed, with no discontinuation of any previous medications.

Communication and Interview Techniques

Healthcare providers must effectively use various communication and interview techniques with different patient populations. In this case, our patient is an 85-year-old woman. Research indicates that elderly individuals typically seek emergency care only when they have severe or life-threatening issues (Lutz et al., 2018). Fortunately, she doesn’t have hearing or visual impairments, so adjustments aren’t needed. The provider should position themselves close to the patient with minimal obstacles between them (Ball et al., 2019). Maintaining eye contact, having an open posture, using appropriate non-verbal cues, and asking relevant follow-up questions are vital for building trust with the patient (Ball et al., 2019). Since this interview takes place in the emergency department, it must be focused and timely. The provider should start with open-ended questions to understand the patient’s main concern and then proceed with appropriate queries to establish trust (Ball et al., 2019). Once rapport is built, the provider can delve into more personal topics, such as lifestyle and socioeconomic status. Questions should be posed one at a time, allowing the patient to respond fully before moving on. Despite the patient’s care transferring to the orthopedic surgeon, it’s crucial to provide educational materials in the form of literature, considering the patient’s heightened emotional state (Hoek et al., 2020). Keeping the patient informed at every step of care is essential to reduce anxiety and ensure safe outcomes.

Risk Assessment Instrument

In this case study, various risk assessment instruments would be beneficial. For this patient, a fall risk assessment tool is most relevant. A commonly used tool is the Johns Hopkins Fall Risk Assessment Tool, which involves seven questions related to age, fall history, elimination, medications, patient care equipment, mobility, and cognition (Johns Hopkins Medicine, n.d.). Scores between 6 and 13 indicate a moderate fall risk, while scores exceeding 13 point to a high fall risk (Johns Hopkins Medicine, n.d.). In this case, our patient is at high risk due to her age (85), recent falls, incontinence, use of medications like antihypertensives and opiates, and impaired mobility.

Additionally, it’s crucial to assess nutritional status. There’s significant evidence linking malnourishment to the risk of falls (Adly et al., 2019). Given that our patient’s BMI is below the recommended level, and she only consumes one meal per day with the occasional supplemental drink, extensive education is needed to emphasize the importance of a healthy diet in preventing future falls and fractures. The Mini Nutritional Assessment Short-Form (MNA) is a commonly used tool for nutritional risk screening in the elderly. It includes components like appetite loss, altered taste and smell, reduced thirst, frailty, and depression, all relevant for the older population (Reber et al., 2019). Using this tool, we can gather information to enable timely nutritional intervention, potentially reducing the risk of falls.

Summary of Health Risk Interview

1. Medical History:
– Can you tell me about your past medical history? Have you had any significant health issues in the past?

2. Living Situation:
– Do you live alone, or do you have any family or friends who can provide support?
– Are there any things in your home that make it hard for you to do daily tasks? Do you use any tools or devices to help you move around?

3. Daily Routine:
– Could you describe a typical day for me?
– How many meals do you have each day, and what kinds of foods are they?
– What are your regular habits related to bowel movements and urination? Do you wake up during the night to use the bathroom?
– Can you shower or bathe on your own, or do you need help? Do you use any devices for safety during these activities?
– How do you handle your medications? Are you consistent in taking them as prescribed? How do you obtain your medications?

4. Falls:
– How frequently do you experience falls, whether it’s in a week, month, or year?
– Is there a specific time of day when you tend to fall, or is there a particular activity you’re engaged in when a fall occurs?

References

Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0

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: Elsevier Mosby.

Hoek, A. E., Anker, S. C., van Beeck, E. F., Burdorf, A., Rood, P. P., & Haagsma, J. A. (2020). Patient discharge instructions in the emergency department and their effects on comprehension and recall of discharge instructions: A systematic review and meta-analysis. Annals of emergency medicine, 75(3), 435-444. https://doi.org/10.1016/j.annemergmed.2019.06.008Links to an external site.

Johns Hopkins Medicine. (n.d.). Fall risk assessment tool. Retrieved from https://www.hopkinsmedicine.org/institute_nursing/_docs/JHFRAT/JHFRAT%20Tools/JHFRAT_acute%20care%20original_6_22_17.pdfLinks to an external site.

Lutz, B. J., Hall, A. G., Vanhille, S. B., Jones, A. L., Schumacher, J. R., Hendry, P., … & Carden, D. L. (2018). A framework illustrating care-seeking among older adults in a hospital emergency department. The Gerontologist, 58(5), 942-952. https://doi.org/10.1093/geront/gnx102Links to an external site.

Reber, E., Gomes, F., Vasiloglou, M. F., Schuetz, P., & Stanga, Z. (2019). Nutritional risk screening and assessment. Journal of clinical medicine, 8(7), 1065. https://doi.org/10.3390/jcm8071065Links to an external site.

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

Additional Risk Factors

As you mentioned, this patient faces several potential risks. Another significant concern for this patient is the possibility of developing pressure injuries (PI) (Elsorady & Nouh, 2023). We can assess this risk using tools like the Waterlow or Braden Scales, both of which are highly sensitive to detecting the likelihood of pressure injuries (Elsorady & Nouh, 2023). Elsorady & Nouh (2023) explained that when a patient’s body mass index (BMI) falls below 18.5, it puts them at risk of developing pressure injuries. Given that this patient has a BMI of 17, it’s clear that she is indeed at risk. Additionally, it’s crucial to conduct a frailty assessment, which includes evaluating cognition and functional status (Elsorady & Nouh, 2023). According to McCance & Huether (2019), frailty is a state that can follow a stressful event, like a fall, and it places the patient at a higher risk of struggling to maintain their body’s balance. Frailty not only increases the risk of more falls but can lead to other adverse outcomes, such as delirium, the need for long-term care due to disability, and even mortality (McCance & Huether, 2019). Since the patient is currently bedbound with a broken hip, her functional status becomes a critical factor in preventing pressure injuries (Elsorady & Nouh, 2023). Therefore, early intervention for pressure injury prevention should be considered right from the moment of admission.

You’ve rightly pointed out the patient’s poor nutritional status. Malnutrition can affect older adults when they’re hospitalized for acute illnesses and have other health problems (Dent et al., 2018). This patient may experience periods of not being able to eat, especially when she needs surgery. Performing a nutritional screening can prompt healthcare providers to request a consultation with a dietitian (Dent et al., 2018). It’s worth noting that even when nutritional assessments triggered best practice alerts for nutritional consultations, as found by Dent et al. (2018), these consultations were sometimes not added to the patient’s care plan.

Furthermore, it’s essential to perform a delirium assessment for this patient (McCance & Huether, 2019). Hospitalized older individuals are at the highest risk for delirium (McCance & Huether, 2019). Delirium can manifest in various ways, including hyperactive, hypoactive, or a combination of both (McCance & Huether, 2019). Hewitt et al. (2019) used the Confusion Assessment Method (CAM) scoring and found that around 10% of acutely hospitalized patients with fractures developed delirium, leading to significantly longer hospital stays (Hewitt et al., 2019). Although interventions for delirium can include early mobility, proper hydration, nutrition, pain management, and sleep quality, it’s crucial to emphasize that prevention is often more effective than treatment. Early screening and non-pharmacologic interventions, such as maintaining hydration and nutrition, can yield positive results for elderly patients (McCance & Huether, 2019).

In conclusion, your comprehensive analysis of these additional risk factors is a valuable contribution. It highlights the complexity of healthcare, especially for older patients, and underscores the importance of taking a holistic approach to patient care. Thank you for sharing these insights.

References

Dent, E., Wright, O., Hoogendijk, E. O., & Hubbard, R. E. (2018). Nutritional screening and dietitian consultation rates in a

geriatric evaluation and management unit. Nutrition & Dietetics, 75(1), 11–16. https://doi.org/10.1111/1747-0080.12391

Elsorady, K. E., & Nouh, A. H. (2023). Biomarkers and clinical features associated with pressure injury among geriatric

patients. Electronic Journal of General Medicine, 20(1), 1–6. https://doi.org/10.29333/ejgm/12636

Hewitt, J., Owen, S., Carter, B.R., Stechman, M.J., Tay, H.S., Greig, M., McCormack, C., Pearce, L., McCarthy, K., Myint, P.K., & Moug, S.J. (2019). The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome. Geriatrics, 4(4), 57. https://doi.org/10.3390/geriatrics4040057

McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children, (8^th ed.). Elsevier.

NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY Sample response 2

NURS-6512N Week 1: Discussion – Building a Health History Sample Response 2

I want to express my gratitude for your comprehensive contribution to the assigned case study. You’ve provided a detailed overview of the communication strategies you’d employ, the questions to ask when gathering the patient’s health history, and the risk assessment tools you’d utilize. Considering the patient’s injury, I wholeheartedly agree that creating a comfortable environment is crucial. Factors like room layout, noise levels, lighting, and temperature should all be taken into account to ensure the patient feels secure. If the advanced practice registered nurse (APRN) can establish trust with the patient from the outset, the interview process and physical assessment are likely to proceed more smoothly. Effective communication by the APRN will determine the patient’s understanding and their ability to grasp their injury and overall care plan. The quality of this communication also affects how well the patient responds and engages with the provider, ultimately influencing the quality of care they receive.

You’ve raised an important point about tailoring education to the patient’s preferences. In my role as a registered nurse (RN), I’m required to conduct a daily education assessment for each patient. Part of this assessment involves understanding how each patient prefers to receive education, whether that’s through verbal explanations, written materials, demonstrations, interpretation services, or virtual methods. Patients vary greatly depending on factors like age, comprehension levels, and cultural backgrounds, so taking these preferences into consideration is essential for effective education. I agree that the elderly population tends to seek hospital care only when their condition is life-threatening, and it’s intriguing to see data that supports this trend. This mindset can indeed lead to delays in receiving necessary care.

I’m familiar with the risk assessment instruments you’ve mentioned, particularly the John Hopkins Fall Risk Assessment Tool. I, too, use this tool for every patient under my care because it’s a valuable indicator of patient safety. This data is often shared with our collaborative staff, including physical therapy, occupational therapy, and speech therapy, as well as case management. It serves as a critical marker for implementing safety measures promptly. It’s important to remember that falls can occur both at home and in the hospital. Knowing that this patient experienced a fall at home puts her at increased risk of falling during her hospital stay due to potential factors like delirium, medication side effects, stimuli, inadequate sleep, and more. The findings from Tyndall et al. (2020) further emphasize the impact of inpatient falls, with an estimated additional length of stay of eight days and an average additional cost of $6,669 per fall in six Australian hospitals (para. 7). These statistics underscore why proper utilization of risk assessment tools is critical for the well-being of patients, providers, healthcare institutions, and organizations.

I also appreciate your emphasis on the importance of nutritional risk assessment. This aspect is often overlooked in practice, but a patient’s nutritional status is a significant indicator of their physical well-being, including its connection to injuries and declining health. Nutrition plays a pivotal role in various aspects of health, from anti-aging and mobility to managing chronic illnesses, promoting sleep, aiding in recovery, maintaining hydration, supporting healing, and enhancing cognitive function. I’ve cared for numerous patients in intensive care who suffered severe falls and injuries due to malnutrition and dehydration. According to Hamrick et al. (2020), there’s a strong link between dehydration and falls. Addressing these risks has the potential to enhance the quality of life for aging patients (para. 4).

The questions you’ve listed, especially those related to falls, are comprehensive and essential. From my own experience, many patients tend to dismiss falls as a natural part of aging, but these incidents often lead to other undiagnosed conditions and concerns. Collecting detailed fall history data is of utmost importance to uncover potential issues such as living in unsafe conditions, underlying cardiac problems, mobility challenges, musculoskeletal injuries or deformities, medication compliance difficulties, and nutritional deficiencies or appetite problems. Additionally, inquiring about the patient’s medications is crucial, as it can provide insights into whether certain medications might be contributing to falls or if adjustments are needed to reduce the risk of further falls. Your insights are invaluable in highlighting the importance of a comprehensive approach to patient care. Thank you for sharing them.

References

Hamrick, I., Norton, D., Birstler, J., Chen, G., Cruz, L., & Hanrahan, L. (2020). Association Between Dehydration and Falls. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 4(3), 259–265. https://doi.org/10.1016/j.mayocpiqo.2020.01.003

Tyndall, A., Bailey, R., & Elliott, R. (2020). Pragmatic development of an evidence-based intensive care unit specific falls risk assessment tool: The Tyndall Bailey Falls Risk Assessment Tool. Australian Critical Care, 33(1), 65–70. https://doi.org/10.1016/j.aucc.2019.02.003 NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY

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