Case 2: 35 year-old white male with history of morbid obesity with disabilities

Case 2: 35 year-old white male with history of morbid obesity
with disabilities in rural setting
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 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.
Resources
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 Process”
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)