Good afternoon Adela and thank you for your thoughtful and detailed post for your assigned patient. Dealing with children of any age while trying to obtain a full and accurate health assessment and history, most especially because you are not dealing only with the child, but with the entire family structure and culture. As noted by Ball et al., to practice with cultural competence requires the provider be mindful of not only their patients’ heritage and ethnicity, but also their socio-economic situation and cultural backgrounds (2019). Of course living in a rural area does not necessarily mean any given person lives in poverty, which would be a stereotype culturally competent practitioners would do well to avoid (Ball et al., 2019). Further, the rural population is anything but homogenous, with African-American, Hispanic/Latino, Asian and Native American populations all growing in these settings throughout the U.S. (Warshaw, 2017).
In addition, while practicing in a rural setting does not necessarily mean all of one’s patients may be economically disadvantaged, there do exist very real and difficult barriers to treatment for this population (Neilson, D’Agostino & Gregory, 2017) These barriers can include the vast geographic distances some must travel to obtain appropriate care, the lack of specialty medical personnel/interventions available at a “reasonable” distance; and the subsequent (and potentially quite substantial) delays in care experienced directly because of these barriers (Nielson, D’Agostino & Gregory, 2017). In this particular scenario, a primary care provider may consider “bundling” services for this preschool patient insofar as possible, to include vaccinations, taking the time to field any and all questions from the family, to provide the family with written education concerning age-appropriate milestones for the child as they grow and what they may reasonably expect next, as well as treatment for whatever condition it was that brought them in with the child in the first place (Nielson, D’Agostino & Gregory, 2017). In addition, there are specific delivery models that may be available to these rural residents and to which they may be referred, to include freestanding emergency departments (FSEDs), a community health worker (CHW) who acts as a liaison between providers and the rural population to help meet those healthcare needs, and telehealth usage where internet access is available to name a few potential initiatives (Rural Health Information Hub (RHIH), 2019).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S. and Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Nielson, M., D’Agostino, D. and Gregory, P. (2017). Addressing Rural Health Challenges Head On. The Journal of the Missouri State Medical Association, 114(5). 363-366.
Rural Health Information Hub (RHIH). (2019). Healthcare Access in Rural Communities. Retrieved from https://www.ruralhealthinfo.org/topics/healthcare-access
Warshaw, R. (October 2017). Health Disparities Affect Millions in Rural U.S. Communities. American Association of Medical Colleges. Retrieved from https://www.aamc.org/news-insights/health-disparities-affect-millions-rural-us-communities
Main Response: 38-year-old Native American pregnant female living on a reservation (Building a health history interview)
Interview Summary:
Patient is welcomed in to the exam room and introductions were made, myself as a student NP and confirmed her appropriate title and preference of address. It is agreed we will address each other by first name. She is a 38-year-old Native American female. She confirms she is pregnant and living on a reservation. To ensure comfort, technology is utilized minimally and not placed between the patient and myself. She is given ample time to express her concerns and provide explanations when needed. She explains her chief concern or reason for the appointment. As this is our first meeting, we must build a thorough health history. We review the history of her pregnancy (involvement of partner, support system, feelings about pregnancy, childbirth, and parenting) and any associated concerns as well as the evolving history surrounding her chief complaint. We discuss her past medical history, family history, and personal and social history. Her past medical history includes any medications (including OTC, vitamins, herbal remedies) she may be taking, illnesses of childhood/young adulthood, emotional/mental health history, immunization records, surgical procedures and injuries, allergies, and screenings. Familial history includes that of parents, siblings, grandparents, aunts, and uncles. Personal and social history includes relationship status, work status, home environment, hobbies, self-care, sexual history, and history of substance use. Additionally, we explore any cultural/religious preferences that may affect her medical care, pregnancy, childbirth, and childrearing. This also includes access to health care either within, or outside of, the reservation. A review of systems is completed including health specifically during the pregnancy. The patient was given the opportunity to verify all retrieved and recorded information. She was included in developing her plan of care moving forward and is agreeable to this plan.
Interview Technique:
Patient-centered communication and care involves focusing on how the patient experiences their wellness/illness as opposed to taking a disease-centered, provider-driven approach (Martyn et al., 2013). It is important to enter in to the patient/provider relationship with the patient and their experience as the focus. To ensure this happens, questions must be open-ended (if possible), and patients should be given time to think and answer thoroughly. Given the opportunity to express their thoughts, feelings, and concerns of their health or illness, patients are more likely to feel emotionally supported, maintain adherence to regimens, report satisfaction with their healthcare experience, and show improvements in physiologic health and recovery (Martyn et al., 2013). While patients may not have the medical expertise to diagnose and treat themselves, they are the experts of their own bodies, thoughts, and feelings. Their input, in the form of subjective information, is pertinent to correct diagnosis and treatment.
HRAs:
One risk assessment instrument that may be used for this patient is the Health Practices in Pregnancy Questionnaire-II. This is a tool that was developed to identify prenatal health practices that may affect the outcome of pregnancy including pre-pregnancy health status, attitude towards pregnancy and childbirth and babies (Lindgren, 2005). This is a validated self-report tool that can be used with all pregnant patients. While many HRA (health risk assessment) tools exist, the benefit really comes from what the medical provider that administers it does with the information. According to Oremus et al. (2011), the feedback and recommendations seemed are the supporting factors that lead to behavioral changes.
Questions:
Since I don’t have any information on why the patient has made the appointment, I am going to try to discover as much about her as I can.
- What concerns brought you in to see me today?
- How have you and your immediate community/family responded to the pregnancy? Do you have support?
- From where have you received medical attention/advice/care? Have you had any prenatal care thus far?
- Do you have any family history of alcoholism, diabetes mellitus, cardiovascular disease, hypertension, cancer? Have you or any family members had difficult pregnancies?
- What was your health status prior to the pregnancy?
- What medications are you taking now? Where you taking any others prior to your pregnancy?
- What is the date of your last menses/estimated due date?
References:
Lindgren, K. (2005). Testing the health practices in pregnancy questionnaire-II. Journal of
Obstetrics, Gynecology, and Neonatal Nursing, 34(4), 465-472.
Doi: 10.1177/0884217505276308
Martyn, K., Munro, M., Darling-Fisher, C., Ronis, D., Villarruel, A., Pardee, M., Faleer, H., &
Fava, N. (2013). Patient centered communication and health assessment in youth.
Nursing Research, 62(6), 383-393. Doi: 10.1097/NNR0000000000000005
Oremus, M., Hammill, A., & Raina, P. (2011). Health risk appraisal [Internet]. Agency for
Healthcare Research and Quality.
Case Study: Adolescent Hispanic/Latino boy living in a middle-class suburb.
How would your communication and interview techniques for building a
health history differ with each patient?
According to Slade (2021), interviewing is a practical approach to collecting essential information involving a patient’s personality and character. In the medical career, interviews are an essential component for gathering data on a one-on-one basis. To have effective communication with this patient, knowing that he is from the Hispanic/Latino ethnic population, firstly, I will want to know his primary language and if the boy is fluent in speaking English. If the patient cannot communicate and comprehend English language fluently, I will engage a professional interpreter from my organization outside a family member. Understanding that effective communication can safeguards patients from possible damage occurring from a misunderstanding (Ali M, 2020).
Additionally, because my patient is an adolescent, I will seek parental consent for the patient to be treated privately unless indicated otherwise by the patient himself. Afterward, I will communicate with the patient using age-appropriate terminology. I will encourage the patient to disclose all necessary concerns and assure him that confidentiality of information will be maintained.
How might you target your questions for building a health history based on the patient’s social determinants of health?
A clear understanding of the patient social history would be beneficial to evaluate the patient’s social determinant of health. Since the patient social determinants of health are his non-medical components that influence his health results. This is the environments in which patient are born, live, age, work and grow and the system shape the conditions of daily life (WHO, 2021). I will assess patient information about parental involvement, education, availability of foods, sleep patterns, extracurricular activities, home stability, and time spent at home, which may help determine the patient social determinants affecting his health. Also, it can help to discover risky behavior that may impact patient health negatively.
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?
Some of the questions that would be appropriate to assess these patient’s health risks would include a question that assesses his involvement in risky behavior. These include factors as poor school performance, low self-esteem, Peer pressure, Lack of intimacy to parents, Poor school performance, Lack of involvement in school extracurricular activities, Vulnerability to advertising, the internet, or social media (Ball et al., 2019) ‘The result of this assessment may be beneficial to identify adolescent for specific behaviors. Therefore, further attention may require if the patient is found to be at risk.
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Dijk et al. (2020) stated that individuals reveal behavioral changes through adolescence and young adulthood and experience numerous life transitions. Due to the age of this patient, he is at risk for risk behavior such as drug abuse, alcohol, sexual misconduct, and suicide. Therefore, it will be beneficial to assess and educate the patient about this topic in a non-judgmental manner.
Risk assessment tools
The HEADSSS is an assessment tool used for adolescent assessment to address factors such as home, education, activities, drug, sex, and suicide for this high-risk population group. (Martin & Ingram, 2018).
Targeted questions
- What is the chief complaint that you have for this appointment?
- What medical conditions do you currently have or have been told that you have before this visit?
- Who lives in your home?
- Being an adolescent, you may be exposed to substances. Do you use any tobacco products, drink alcohol, or use drugs?
- Are you currently in a relationship?
- Do you ever think about harming yourself?
References
Ali M, N. T. (2020, August 28). Benefits of Effective Communication in Nursing: Communication Skills 1. Nursing Times. https://www.nursingtimes.net/clinical-archive/assessment-skills/communication-skills-1-benefits-of-effective-communication-for-patients-20-11-2017/.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s Physical Examination: An Interprofessional Approach. Elsevier Health Sciences.
Dijk, M. P. A. V., Hale, W. W., Hawk, S. T., Meeus, W., & Branje, S. (2020, May 13). Personality Development from Age 12 to 25 and its Links with Life Transitions. Wiley Online Library. https://onlinelibrary.wiley.com/doi/full/10.1002/per.2251.
Slade, S. (2021, May 4). Interview Techniques. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK526083/.
WHO. (2021). Social determinants of health. World Health Organization. .
Martin N., and Ingram L. (2018) HEADSSS ASSESSMENT. Retrieved November 27, 2019 from https://teachmepaediatrics.com/community/holistic-care/headsss-assessment
S/T/U/V/W/X/Y/Z: Case G Pre-school-aged white female living in a rural community
Discussion week 1 main post
This interview will be done on a pre-school-aged white female living in a rural community. Due to the patient’s age, the parent/caregiver will be asked the interview questions. To gather adequate information there are communication skills required for the provider to use that will address the health of the child. Strategies to use in the interview include open-ended questions, attentive listening, using simple words, and positive non-verbal body language. Effective communication involves a wide amount of factors. Hutchison (2020) explained that communication can be hidden in verbal messages or conveyed by facial expressions or gestures. Insightful questions are better gathered when the patient is fully engaged in the interview. Using specific tones and speech that are geared towards the child’s learning ability is very important. Medical jargon must be avoided to lessen the frustrations and missed information needed to gain insight into the child’s likes and dislikes. It is important not to become paternalistic or use an authoritarian approach. When starting the interview, the Practitioner must professionally introduce her/himself to the parent and child using all of the above strategies to gain trust and confidence in the parent and child. Good lighting in a quiet place is preferred to enhance privacy. Keep the parent informed of the intent of the interview with open-ended questions. Encourage feedback throughout the interview for clarity. Fawcett and Rhynas (2012) expressed the importance of obtaining a precise and full health assessment to lead to accurate diagnosis and appropriate treatment.
The obesity risk assessment tool will be used for the interview to gather detailed insight into the child’s eating status. Townsend et al. (2018) explained that these risk assessment tools assist professionals with programmatic needs for the child. Nutritional agencies benefit from the information gathered to determine how to meet the patient’s needs more adequately. This tool can further assist with the early identification of needed nutritional counseling.
Questions about the child should be directed to the parent/caregiver to gather the best baseline information. Some questions to ask are as follows:
-
- What concerns do you have about your child’s eating habits?
- Have your child experienced any allergic reactions to medications or foods?
- Have your child experienced any illnesses?
- What concerns you the most about your child’s health?
- Do you have any concerns about not having enough food in your home?
Practitioners are well equipped to gather information during a health history interview. Using non-medical terms with professional behavior assists a Practitioner with obtaining personal insight into the patient’s concerns and needs. Including the patient’s parent/caregiver gives a patient-centered focus concept. Children living in rural communities are at higher risk for developmental delays and nutrition disadvantages related to lack of access to adequate health care and financial obstacles. Identifying risks early in the child’s health history interview is essential to positive outcomes. When the parent of the patient is fully involved in the child’s care, outcomes are geared towards a healthy lifestyle.
NURS 6512 Week 1 Discussion Building a Health History References
Fawcett, T., & Rhynas, S. (2012). Taking a patient history: the role of the nurse. Nursing Standard, 26(24), 41–46.
Hutchison, L. M. (2020). SECTION II: Critical Abilities in Professional Nursing Practice: CHAPTER 6: Effective Communication. Advancing Your Career: Concepts of Professional Nursing (7th Edition), 7th, 99–118.
Townsend, M. S., Shilts, M. K., Styne, D. M., Drake, C., Lanoue, L., & Ontai, L. (2018). An Obesity Risk Assessment Tool for Young Children: Validity With BMI and Nutrient Values. Journal of Nutrition Education and Behavior, 50(7), 705–717.
