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BUILDING A HEALTH HISTORY: COMMUNICATING EFFECTIVELY TO GATHER APPROPRIATE HEALTH-RELATED INFORMATION Effective communication is vital to constructing

BUILDING A HEALTH HISTORY: COMMUNICATING EFFECTIVELY TO GATHER APPROPRIATE HEALTH-RELATED INFORMATION

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. 

There may also be significant cultural factors. In May 2012, Alice Randall wrote an article for  The New York Times on the cultural factors that encouraged Black women to maintain a weight above what is considered healthy. Randall explained from her observations and her personal experience, as a Black woman, that many African American communities and cultures consider women who are overweight to be more beautiful and desirable than women at a healthier weight. As she put it, “Many black women are fat because we want to be” (Randall, 2012). 

Randall’s statements sparked a great deal of controversy and debate at the time; however, they emphasize an underlying reality in the healthcare field: Different populations, cultures, and groups have diverse beliefs and practices that impact their health. APRNs and other healthcare professionals should be aware of this reality and adapt their health assessment techniques and recommendations to accommodate diversity.

As an advanced practice nurse, you must build a patient health history that takes into account all of the factors that make a patient unique and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with each patient, but it will also enable you to more effectively gather the information needed to assess a patient’s health risks. 

For this first Assignment, you will take on the role of an APRN who is building a health history for a particular patient assigned by your Instructor. You will consider how social determinants of health and specific cultural considerations will influence your interview and communication techniques as you work in partnership with the patient to gather data for an accurate health history.  

Note: You are expected to draw on the resources for  both Week 1 and Week 2 when completing your Assignment. 

Resources

Be sure to review the Learning Resources before completing this activity. Click the weekly resource links to access the resources. 

WEEK 1 WEEKLY RESOURCES

 

WEEK 2 WEEKLY RESOURCES

To prepare:

· Reflect on your experience as an advanced practice nurse and on the information provided in the Week 1 Learning Resources on building a health history and the Week 2 Learning Resources on diversity issues in health assessments. 

· By Day 1 of this week, your Instructor will assign a case study for this Assignment.  Note: Please see the  Course Announcements section of the classroom for your Case Study Assignment. 

· Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of your assigned patient. 

· Consider how you would build a health history for the patient. What questions would you ask? How might you target your questions based on the patient’s social determinants of health? How would you frame the questions to be sensitive to the patient’s background, lifestyle, and culture? 

· Identify any potential health-related risks, based on the patient’s age, gender, ethnicity, or environmental setting, which should be taken into consideration. 

· What risk assessment instruments would be appropriate to use with this patient? 

· What questions would you ask to assess the patient’s health risks?  

· Select  one (1) risk assessment instrument discussed in the Learning Resources, or another tool with which you are familiar, related to your selected patient. 

· Develop  five (5) targeted questions you would ask the patient to build their health history and to assess their health risks. 

· Think about the challenges associated with communicating with patients from a variety of specific populations. What communication techniques would be most appropriate to use with this patient? What strategies can you as an APRN employ to be sensitive to different cultural factors while gathering the pertinent information?

Assignment: Building a Health History With Cultural and Diversity Awareness  

Include the following: 

· Explain the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Be specific. 

· Explain the issues that you would need to be sensitive to when interacting with the patient, and why.  

· Describe the communication techniques you would use with this patient. Include strategies to demonstrate sensitivity with this patient. Be specific and explain why you would use these techniques. 

· Summarize the health history interview you would conduct with this patient. Provide at least  five (5) targeted questions you would ask the patient to build their health history and to assess their health risks. Explain your reasoning for each question and how you frame each for this specific patient. 

· Identify the risk assessment instrument you selected, and then justify why it would be applicable to your assigned patient. Be specific. 

By day 7 of Week 2

Submit your Assignment.

submission information

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Case study-SJ is a 28 y/o Lebanese Muslim female who is in her first year of graduate school, living in university housing. This is her first year in the US. She is coming to the university clinic for a physical exam.

· patient. Be specific. 

WEEK #2

You will complete your first Assignment this week on building a health history for a patient that takes into consideration multiple factors that make the patient unique.

This week, you will also be introduced to the i-Human Patients software, which you will use to complete specific case studies in upcoming weeks of the course. You will have required orientation materials to review. You will also have an i-Human Patients practice case to begin—with multiple attempts allowed—and the final submission due in Week 3. Take time to familiarize yourself fully with i-Human Patients in the next 2 weeks and make the most of the opportunity to practice working in i-Human Patients.

 

LEARNING OBJECTIVES

Students will:

· Analyze communication techniques used to obtain patients’ health histories based upon social determinants of health 

· Analyze diversity considerations in health assessments 

· Analyze health-related risks 

· Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information 

· Apply concepts, theories, and principles related to examination techniques, functional assessments, and cultural and diversity awareness in health assessment 

· Apply principles of health assessment documentation  

 

ASSIGNMENTS:

Assignment: Building a Health History With Cultural and Diversity Awareness  

Include the following: 

· Explain the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Be specific. 

· Explain the issues that you would need to be sensitive to when interacting with the patient, and why.  

· Describe the communication techniques you would use with this patient. Include strategies to demonstrate sensitivity with this patient. Be specific and explain why you would use these techniques. 

· Summarize the health history interview you would conduct with this patient. Provide at least  five (5)targeted questions you would ask the patient to build their health history and to assess their health risks. Explain your reasoning for each question and how you frame each for this specific patient. 

Identify the risk assessment instrument you selected, and then justify why it would be applicable to your assigned

Rubric

NURS_6512_Week 2_Assignment 1_Rubric

NURS_6512_Week 2_Assignment 1_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeExplain the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Be specific.

15 to >12.0 pts

Excellent

The response clearly, accurately, and in detail explains the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the assigned patient.

12 to >9.0 pts

Good

The response accurately explains the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the assigned patient.

9 to >6.0 pts

Fair

The response vaguely and with some inaccuracy explains the socioeconomic, spiritual, lifestyle, and other cultural factors associated with the assigned patient.

6 to >0 pts

Poor

The response is inaccurate and/or missing explanations of the socioeconomic, spiritual, lifestyle, and other cultural factors associated with the assigned patient.

15 pts

This criterion is linked to a Learning OutcomeExplain the issues that you would need to be sensitive to when interacting with the patient, and why.

15 to >12.0 pts

Excellent

The response clearly, accurately, and in detail explains the issues to be sensitive to when interacting with the patient; explanations why are clear, accurate, and detailed.

12 to >9.0 pts

Good

The response accurately explains the issues to be sensitive to when interacting with the patient; explanations why are accurate.

9 to >6.0 pts

Fair

The response vaguely and with some inaccuracy explains the issues to be sensitive to when interacting with the patient; explanations why are vague and/or inaccurate.

6 to >0 pts

Poor

The response is inaccurate and/or missing explanations of the issues to be sensitive to when interacting with the patient; explanations why are inaccurate or missing.

15 pts

This criterion is linked to a Learning OutcomeDescribe the communication techniques you would use with this patient. Include strategies to demonstrate sensitivity with this patient. Be specific and explain why you would use these techniques.

15 to >12.0 pts

Excellent

The response clearly and accurately identifies and describes in detail communication techniques to use with the patient, including specific strategies to demonstrate sensitivity with this patient, and a detailed explanation of why to use these techniques.

12 to >9.0 pts

Good

The response accurately identifies and describes communication techniques to use with the patient, including specific strategies to demonstrate sensitivity with this patient, and an explanation of why to use these techniques.

9 to >6.0 pts

Fair

The response vaguely and with some inaccuracy identifies and describes communication techniques to use with the patient, including strategies to demonstrate sensitivity with this patient, and a vague explanation of why to use these techniques.

6 to >0 pts

Poor

The response identifies inaccurately and/or is missing descriptions of communication techniques to use with the patient, including inaccurate or missing strategies to demonstrate sensitivity with this patient, and an inadequate or missing explanation of why to use these techniques.

15 pts

This criterion is linked to a Learning OutcomeSummarize the health history interview you would conduct with this patient. Provide at least five (5) targeted questions you would ask the patient to build their health history and to assess their health risks. Explain your reasoning for each question and how you frame each for this specific patient.

25 to >22.0 pts

Excellent

The response clearly, accurately, and in detail summarizes the health history interview to conduct with this patient, including at least five targeted questions to ask to build the health history and assess health risks, with detailed explanations for the wording of each question and why it is asked.

22 to >19.0 pts

Good

The response accurately summarizes the health history interview to conduct with this patient, including five targeted questions to ask to build the health history and assess health risks, with explanations for the wording of each question and why it is asked.

19 to >16.0 pts

Fair

The response vaguely summarizes the health history interview to conduct with this patient, including five questions to ask that are vague or lacking specificity to build the health history and assess health risks, with vague explanations for the wording of each question and why it is asked.

16 to >0 pts

Poor

The response inadequately summarizes the health history interview to conduct with this patient, including fewer than five questions that are inadequate for building the health history and assessing health risks, with inadequate or missing explanations for the wording of each question and why it is asked.

25 pts

This criterion is linked to a Learning OutcomeIdentify the risk assessment instrument you selected, and then justify why it would be applicable to your assigned patient. Be specific.

15 to >12.0 pts

Excellent

The response clearly and accurately identifies the selected risk assessment instrument, and provides detailed and specific justification for why it is applicable to the assigned patient.

12 to >9.0 pts

Good

The response accurately identifies the selected risk assessment instrument, and provides specific justification for why it is applicable to the assigned patient.

9 to >6.0 pts

Fair

The response vaguely identifies the selected risk assessment instrument, and provides vague justification for why it is applicable to the assigned patient.

6 to >0 pts

Poor

The response inadequately identifies the selected risk assessment instrument, and provides inadequate or missing justification for why it is applicable to the assigned patient.

15 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting: Paragraph Development and Organization — Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused and neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts

Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting: English Writing Standards — Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with understanding.

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting: APA The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with understanding.