NURS 6512 BUILDING A HEALTH HISTORY ESSAY

NURS 6512 BUILDING A HEALTH HISTORY ESSAY

NURS 6512 BUILDING A HEALTH HISTORY ESSAY

Building a Health History

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The case concerns an adolescent Hispanic/Latino boy living in a middle-class suburb. When interviewing this client, I would ask about his health concerns, including his primary reason for the visit. During the interview, I would ask the client about his health prevention and promotion activities, sexual activity, and mental health issues. I would be warm and friendly to the client, shake his hand, and make eye contact. I would also reassure the patient about the confidentiality of the information he provides (Takeuchi et al., 2021). This will help the client feel comfortable and encourage him to convey his health concerns. Furthermore, I will express interest in the client’s life, not just his medical concerns.

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   Effective communication techniques are crucial in eliciting information from adolescents. When discussing sexual activity, I will introduce the questions about sexual activity comfortably. If the patient expresses confusion about sexual activity, the nurse will clarify for him (Savoy et al., 2020). In addition, I will ask appropriate questions, even though the patient and I are uncomfortable. I will also acknowledge the awkwardness of the questions and normalize it by mentioning that I ask all adolescent clients these questions (Shafii et al., 2019). Furthermore, I will articulate to the client the patient’s need to be listened to and make him not feel pressured into disclosing his feelings. I would also use humor to empathize with the client, which will help get a positive response from him.

The CRAFFT questionnaire can be used for this client. It is used to screen for alcohol and substance abuse in adolescents (Ball et al., 2019). It is ideal for this patient since he is an adolescent living in a middle-class suburb, which usually has a high prevalence of adolescent alcohol and substance abuse.

Target Questions

  1. What health concerns do you have today?
  2. Other than health issues, what social or psychological problems are you experiencing?
  3. What factors often make you psychologically distressed?
  4. How is your relationship with your peers in school and at home?
  5. What is your sexual preference?

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: Elsevier Mosby.

Savoy, M., O’Gurek, D., & Brown-James, A. (2020). Sexual health history: techniques and tips. American Family Physician, 101(5), 286–293.

Shafii, T., Benson, S. K., & Morrison, D. M. (2019). Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study. Journal of medical Internet research, 21(7), e13220. https://doi.org/10.2196/13220

Takeuchi, Y. L., Bonvin, R., & Ambresin, A. E. (2021). ‘Demystifying’ the encounter with adolescent patients: a qualitative study on medical students’ experiences and perspectives during training with adolescent simulated patients. Medical education online, 26(1), 1979445. https://doi.org/10.1080/10872981.2021.1979445

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M/N/O/P/Q/R: Case E Adolescent Hispanic/Latino boy living in a middle-class suburb

BUILDING A HEALTH HISTORY

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

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.

Chapter 1, “The History and Interviewing Proce

This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

Chapter 5, “Recording Information”

This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

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 unitLinks to an external site.. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0

Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the EDLinks to an external site.. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015

Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced levelLinks to an external site.. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Shadow Health. (2021). Welcome to your introduction to Shadow HealthLinks to an external site.. https://link.shadowhealth.com/Student-Orientation-Video

Shadow Health. (n.d.). Shadow Health help deskLinks to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us

Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students.

Document: Shadow Health Nursing Documentation Tutorial Download Shadow Health Nursing Documentation Tutorial(Word document)

Required Media

Welcome and General Course Guidelines

Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

Module 1 Introduction

Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

Building a Comprehensive Health History – Week 1 (19m)

Optional Resources

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.

2, “History Taking and the Medical Record” (pp. 14–27)

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 Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!

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

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NURS_6512_Week_1_Discussion_Rubric

NURS_6512_Week_1_Discussion_Rubric

Criteria Ratings Pt This criterion is linked to a Learning OutcomeMain Posting

50 to >44.0 pts

Excellent

“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

44 to >39.0 pts

Good

“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

39 to >34.0 pts

Fair

“Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.

34 to >0 pts

Poor

“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.

50 pts

This criterion is linked to a Learning OutcomeMain Post: Timeliness

10 to >0.0 pts

Excellent

Posts main post by Day 3.

0 pts

Fair

N/A

0 pts

Good

N/A

0 pts

Poor

Does not post main post by Day 3.

10 pts

This criterion is linked to a Learning OutcomeFirst Response

18 to >16.0 pts

Excellent

“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.

16 to >14.0 pts

Good

“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.

14 to >12.0 pts

Fair

“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

12 to >0 pts

Poor

“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.

18 pts

This criterion is linked to a Learning OutcomeSecond Respons

17 to >15.0 pts

Excellent

“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.

15 to >13.0 pts

Good

“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.

13 to >11.0 pts

Fair

“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

11 to >0 pts

Poor

“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.

17 pts

This criterion is linked to a Learning OutcomeParticipation

5 to >0.0 pts

Excellent

Meets requirements for participation by posting on three different days.

0 pts

Fair

N/A

0 pts

Good

N/A

0 pts

Poor

Does not meet requirements for participation by posting on three different days.

5 pts

Total Points: 100

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