NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Case G: A pre-school aged white female living, in a rural community.
My patient assigned to me is a pre-school-aged white female from a rural community. The preschool years are defined as the years between the
ages of two and five. A rural community has a low population density, dwellings and businesses that are far apart from one another. As a result,
rural and underserved areas experience significant difficulties in accessing healthcare, which can impede timely and adequate care, potentially
leading to bad health outcomes (NCSL, 2021).
As a nurse practitioner, I will establish courtesy, comfort, connection, and confirmation for this youngster by building a positive patient relationship based on effective
communication (Ball et al., 2019). The goal would be to establish contact with this child. I would base my communication approaches on the RESPECT Model. RESPECT
is an acronym that stands for rapport, empathy, support, collaboration, explanations, cultural competency, and trust. It will assist me in becoming more efficient and patient
centered. As a practitioner, I will sit close to the parent, and the child should be secure on the parent’s lap or the exam table with the parent standing nearby (Ball et al.,
2019). My patient is a preschooler, who implies she is still not a trustworthy historian. I would do an open-ended interview with the child’s parents/guardians, paying close
attention to nonverbal signs. Open-ended inquiries are required to elicit a more extensive and elaborate response. This child is transitioning from infancy to preschool, and t
he provider can anticipate some significant intellectual, social, and emotional changes with this age group (healthychildren.org, 2019). Cognitive development in preschool
children varies, and the practitioner must be familiar with various communication approaches to assess each patient on their level.
I would use the CAGE Questionnaire to identify health risks, including Principal Concerns, History of Current Illness, Past Medical History, Family History, Personal and
Social History, and Developmental Milestones (Wu &Orlando, 2015). The nurse practitioner can communicate directly to the patient, asking open-ended questions and
ensuring that the kid and the adult (parent) are included in the main issues of the interview (Ball et al., 2019). One impediment to this conversation would be a child who is
adopted or in foster care and may not have a complete history (Ball et al., 2019). Furthermore, permission by proxy can be an issue if the child is a minor and is brought into
the office with someone other than the custodial parent or guardian (Ball et al., 2019). In both instances, the practitioner must be familiar with the protocol and procedure for
the specific health care facility.
Summary
Furthermore, will use open-ended question during the interview to obtain data on the problem, allergies, medications, and vaccines. This child is also
said to live in a rural community; thus, while building the health history and subsequent treatment plan, environment, access to health care,
socioeconomic status (access to excellent health care), and cultural variations must be considered.
Targeted Questions:
- What is your relationship to the child?
- Where does your child live and spend most of his/ her time?
- Is there a specific disease or condition that you have concern with today?
- Is there any emotional, behavioral, or developmental concerns with your child?
- Does the child have any known allergies? If so, what is the specific reaction?
- Is the child up to date on her immunization schedule? Do you have proof of the records?
- What medications is the child taking or if the child is on any on any special diet?
References:
Agency for Toxic Substance and Disease Registry. (2019). Taking a Pediatric Exposure
History. Retrieved from https://atsdr.cdc.gov
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.
Healthychildren.org. (2019). Ages and Stages. Retrieved from https://healthychildren.org
National Agricultura Library. (2019). What is Rural? Retrieved from https://nal.usda.gov
Schochet, L. (2019). 5 Facts To Know About Child Care in Rural America. Retrieved from
https://americanprogress.org
Wu, R.R. & Orlando, L.A. (2015). Implementation of health risk assessments with family
health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508-513.
rersponse
I agree with you and also think that it is important to ask open-ended questions paying close attention to nonverbal signs. This is especially important because as you mentioned, t5he patient is a preschool-age female. At this age, children don’t always know how to explain things and their nonverbal signs of communication can reveal important aspects such as abuse, maltreatment, malnourishment and so on. Sometimes it is difficult to understand exactly what child abuse and neglect are.
Child abuse can be a one-time occurrence but more often it is a pattern of behavior involving regular physical attacks or acts of deprivation or molestation (Wholechild.org, et al, 2018). I would ask questions that use the child’s own vocabulary, but that is a little vague. For example, “Has someone been touching you?” In this context, “touching” can mean different things, but it is likely a word the child is familiar with. The child can respond with questions or comments that will help better gauge the situation like, “No one touches me except my mom at bath time,” or “You mean like the way my cousin touches me sometimes?” (Bazilchiuk, N., et al, 2016).
Unfortunately, from my experience working in a children’s psychiatric unit, we do get a lot of preschool children that suffered some form or type of abuse, and most of the time, they do not realize that what happened to them is not all right.
References
Bazilciuk, N., (2018). How do you talk to a child if you suspect sexual abuse? Retrieved from https://sciencenorway.no/children-forskningno-norway/how-do-you-talk-to-a-child-if-you-suspect-sexual-abuse/1440322
Whole child (2018). How to identify child abuse ages 0-5. Retrieved from https://www.thewholechild.org/parent-resources/age-0-5/how-to-identify-child-abuse-ages-0-5/
Week 1: Building a Comprehensive Health History
According to a 2011 Gallup poll, nurses are ranked as the most trusted professionals in the United States. One of the most admired nursing skills is the ability to put patients at ease. When patients enter into a healthcare setting, they are often apprehensive about sharing personal health information. Caring nurses can alleviate the hesitance of patients and encourage them to be forthcoming with this information.
The initial health history interview can be an excellent opportunity to develop supportive relationships between patients and nurses. Nurses may employ a variety of communication skills and interview techniques to foster strong bonds with patients and to effectively facilitate the diagnostic process. In conducting interviews, advanced practice nurses must also take into account a range of patient-specific factors that may impact the questions they ask, how they ask those questions, and their complete assessment of the patient’s health.
This week, you will consider how social determinants of health such as age, gender, ethnicity, and environmental situation impact the health and risk assessment of the patients you serve. You will also consider how social determinants of health influence your interview and communication techniques as you work in partnership with a patient to gather data to build an accurate health history.
Learning Objectives
Students will:
- Analyze communication techniques used to obtain patients’ health histories based upon social determinants of health
- Analyze health-related risk
- Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
Learning Resources
Assignment: Course Acknowledgement
This mandatory assignment is an acknowledgement that you fully understand the course guidelines.
By Day 3 of Week 1
Submit your Assignment.
Submission and Grading Information
Submit Your Assignment by Day 3 of Week 1.
To complete this assignment, follow the link below and answer the questions provided.
Week 1 Assignment
Discussion: 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.
Photo Credit: Sam Edwards / Caiaimage / Getty Images
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.
The scenario I will be writing on is “A 14-year-old biracial male living with his grandmother in a high-density public housing complex”.
Collecting patient data is a core step in the nursing process and healthcare professionals usually develop a relationship with their patients during the history and interviewing process (Ball et al., 2019). I will first introduce myself to the patient and establish privacy. When interviewing the patient effective communication is important. It is necessary to establish a positive patient relationship by ensuring courtesy, comfort, connection, and confirmation.
Teenagers are exposed to many external and internal struggles and are expected to cope with hormonal changes, puberty, social and parental forces, work and school pressures, and other problems of life. During adolescence, individuals may also be exposed to risky behaviors and need help in making the right decisions. As such, teenagers may be unwilling to speak with healthcare providers. There is, therefore, the need to establish privacy and providers must be sensitive to the needs and situation of the patient. Providing a safe place for the adolescent to speak freely is a goal of the healthcare provider (Ball et al., 2019).
The health assessment will be from head-to-toe and going through each system of the body. During the interview process, I will ask the patient open-ended questions regarding his health, to allow him to share more information, including his feelings, attitudes, and understanding of the subject. Examples of open-ended questions that may be asked to a 14- year-old include:
- Tell me about your living situation, who lives in your home, and how are things at home?
- Tell me about your friends and what activities do you do with your friends?
- Give me 3 words to describe yourself
- Tell me about your bedtime routine, how many hours of sleep do you get each night?
- Describe the meals you consume in a typical day
Risk assessment explores the behavioral and lifestyle changes and influences decisions regarding treatments (Wu & Orlando, 2015). Specific screening tools have been developed for gathering the psychosocial history of adolescents (Sullivan, 2019). The screening tool for adolescent issues is the Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety (HEEADSSS). This interview format is flexible and designed for adolescents because physical and social threats are common during adolescent age.
References
Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby
Sullivan, D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis
Wu, R., & Orlando, L. (2015). Implementation of Health Risk Assessments with Family Health History: Barriers and Benefits.” Postgraduate Medical Journal, no. 1079: 508. doi:10.1136/postgradmedj-2014-133195
response
I really like your question about asking the patient to use three words to describe himself. That forces the patient to really think about their answer and can tell you a lot about how they see themselves. One of the questions on our child and adolescent nursing admission assessment for the inpatient psych unit is to tell us their strengths and weaknesses. It is amazing what you can learn just from those questions.
I think another good assessment for this patient is to check for a lead level. High-density public housing has the potential for lead-based paint. Kids who live in public housing at or below the poverty level in housing built before 1978 are at the greatest risk. Lead exposure can lead to brain damage and learning and behavioral problems, which is unfortunate because it is preventable (Centers for Disease Control and Prevention, 2020). Even though lead
exposure behavioral problems tend to appear in children younger than this patient, it can still provide information about the patient’s living situation and behavior. Asking the patient’s parent or guardian about behavior changes and their living situation can help the provider determine if the patient is at a high risk of exposure (Mayo Clinic, 2019).
References
Center for Disease Control and Prevention. (2020). Health effects of lead exposure. Retrieved from https://www.cdc.gov/nceh/lead/prevention/health-effects.htm
Mayo Clinic. (2019). Lead poisoning. Retrieving from https://www.mayoclinic.org/diseases-conditions/lead-poisoning/diagnosis-treatment/drc-20354723
