Building a Comprehensive Health History NURS 6512

Week 1 Discussion

Sample Paper

One must comprehend the significance of a thorough history document once they have developed a relationship and a thorough health history. This document frequently serves as the foundation for a patient’s entire medical management plan (Sullivan, 2012). Everyone has a story, and the health history document should provide a complete and accurate account of the patient’s medical history.

Any professional who reads the patient’s health history should have a good understanding of them. Ball, Dains, Flynn, Solomon, and Stewart (2015) claim that the first encounter between the clinician and the patient establishes the foundation for a fruitful relationship, gives the patient a chance to voice any concerns, identifies expectations for a successful outcome, and fosters the development of a partnership in one’s healthcare. Building a Comprehensive Health History NURS 6512

The role of a clinician in gathering a thorough health history from a 16-year-old pregnant white teen living in an inner-city neighborhood will be discussed this week. A risk assessment tool is also used, along with five or more specific questions that could be asked in this particular circumstance, along with a review of communication techniques. Building a Comprehensive Health History NURS 6512. Building a Comprehensive Health History, NURS 6512

Interview and Communication Techniques

Adolescents is a time between childhood and adulthood where risky behaviors are experimented and where privacy and confidentiality are important to be less hesitant in discussing their concerns (Ball, et.al., 2015). Effective communication with adolescents requires seeing the patient alone, tailoring the discussion to the individual patient, and understanding the role of the parents with confidentiality (Ham, & Allen,Building a Comprehensive Health History NURS 6512 2012).

According to Thompson (2010), obtaining a necessary ‘social history’ of each teenager can help to gain vital information about their relationships, assess the needs of the individual, and identify possible problems throughout the pregnancy. There are a number of issues relevant to teenage parents, such as; age, emotional maturity, relationship with parents/partner, educational needs, looked after children, social situation, and supporting young fathers-to-be (Thompson,Building a Comprehensive Health History NURS 6512 2010).

The social history is a series of detailed questions creating the basis of the assessment and care plan. The care plan and assessment information is updated throughout the pregnancy and the plan is altered as the situation demands (Thompson, 2010).

Questions should be open-ended so that feedback is prompted, yet, declining to answer should be acceptable as well (Ball, et.al., 2015). For questions that are answered, further investigation can be encouraged to continue the evaluation of the situation. In addition, a screening tool or questionnaire at the pre-visit stage can also encourage a non-forced conversation by silently writing the concern rather than verbalizing the concern (Ball, et.al., 2015). Building a Comprehensive Health History NURS 6512

Questions should pertain to thorough evaluation of her partner(s), sexually transmitted infection (STI) history, last menstrual cycle, medical history, previous gynecological visits, social/personal history (including current/previous smoking, drug or alcohol use), family history, and current outlook on the pregnancy. A time for the patient to ask any questions or express any concerns should be followed up, so that the patient is still involved and can feel in control and knowledgeable of the situation. Building a Comprehensive Health History NURS 6512

A full head to toe assessment should be completed, including fetal heart tones. The patient-provider relationship should be respectful, useful, and effective with honest responses, making good eye contact, and maintaining non-judgmental respect of wishes.

Risk Assessment Instruments

As above, obtaining a social history can not only assess risky behaviors, discussing general social behaviors can also help to open the door to a better patient-provider relationship. The use of the screening tools HEEADSSS and PACES can guide adolescent issues such as sex, drugs, smoking, alcohol, peer pressure, home environment, and school (Ball, et al.,Building a Comprehensive Health History NURS 6512 2015). The answers to these questions can help the provider obtain the knowledge and readiness of the patient’s needs for further educational needs and assistance from the provider (Ball, et al., 2015).

Health-Related Risk Potential

Other situations may arise that can be detrimental health concerns for the patient and the unborn child. Due to age, teenagers are at risk for not obtaining adequate prenatal care. This screens for medical problems in both mother and baby, monitors the baby’s growth, and deals quickly with any complications that arise. Prenatal vitamins with folic acid (ideally taken before getting pregnant) are essential to help prevent certain birth defects, such as neural tube defects (CDC, 2010). Building a Comprehensive Health History NURS 6512

Pregnant teens have a higher risk of getting high blood pressure (pregnancy-induced hypertension) than pregnant women in their 20s or 30s (CDC, 2010). They also have a higher risk of preeclampsia, which is a dangerous medical condition that combines high blood pressure with excess protein in the urine, swelling of a mother’s hands and face, and organ damage (CDC, 2010). In addition, pregnant teens may be at higher risk of postpartum depression (CDC, 2010). Building a Comprehensive Health History NURS 6512

Target Questions

Several target questions may be used to help determine risks and build an up-to-date accurate health history. These questions may also help to obtain sexual history, any violence or potential violence, family support, and any other potential high risk endeavors that may harm the fetus or the patient. The questions below may be asked in a different sequence depending on the conversation and situation. Building a Comprehensive Health History NURS 6512

When was your last menstrual cycle?
Was this a planned pregnancy?
Have you had any previous pregnancies?
What is your current outlook on this pregnancy?
How many sex partners have you had?
Do you drink alcohol, smoke, or do recreational drugs? If so, how often?
Do you have a good relationship with your parents?
Have you ever been ‘in care’ or a ‘looked after child’?
How does your parents feel about you being pregnant?
Do you think your parents will support you?
How are you doing in school?
Do you have any questions for me?

Building a Comprehensive Health History NURS 6512 Conclusion

Encouragement and education can go a long way with a teenager who is pregnant. A practitioner that can listen and treat to the best of their ability without judgement is one who has built a relationship on trust, honesty, and respect with the patient, no matter the age or circumstance. Thus, obtaining a health history that is accurate and reflects the patient’s situation, identifying the possible risk factors or complications that could arise.

Building a Comprehensive Health History NURS 6512 References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Center for Disease Control and Prevention (CDC). (2010). Reproductive Health: Teen Pregnancy. Retrieved from: http://www.cdc.gov/TeenPregnancy/index.htm.
Ham, P., & Allen, C. (2012). Adolescent health screening and counseling. American Family Physician, 86(12), 1109-1116.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.
Thompson, S. (2010). The complexities of supporting teenagers in pregnancy. British Journal Of Midwifery, 18(6), 368-372.