Module 1: Comprehensive Health History

What’s Happening in This Module?

This course is composed of four (4) separate modules. Each module consists of an overarching topic in which each week within the module includes specific subtopics for learning. As you work through each module, you will have an opportunity to draw upon the knowledge you gain in various Digital Clinical Experiences (DCE) and lab assignment components that will be due throughout each of the modules.

Module 1: Comprehensive Health History is a 1-week module, Week 1 of the course, in which you will examine how social determinants of health such as age, gender, ethnicity, and environmental situations 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.

Go to the Week’s Content

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

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 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)

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12.  https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x

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.

Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3.

Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8

Shadow Health Support and Orientation Resources

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

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw- Hill Medical.

• Chapter 2, “History Taking and the Medical Record” (pp. 15–33)

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)

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.

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.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 1 Discussion Rubric

Post by Day 3 of Week 1 and Respond by Day 6 of Week 1

To Participate in this Discussion:

Week 1 Discussion Sample Paper

NURS 6512 Week 1 Discussion – Advance Health Assessment and Diagnostic Reasoning

Clinical Assessment

Student’s Name:

Institutional Affiliation:

Clinical Assessment

A 55 Year Old Asian Female Living in a High-Density Public Housing Complex

The patient in this scenario is a 55-year-old Asian female living in a high-density poverty housing complex. The first thing I will do is to find out if she understands English. In case she doesn’t, I will make arrangements to have a translator. While interviewing, I need to be competent in the cultural aspect to avoid any actions or words that would be inflicted on her culture. I will be able to do this by maintaining a high level of sensitivity to her heritage, sexual orientation, and social-economic conditions (Aranda, Davies & Jackevicius, 2019). I would also pay attention to her ethnicity and general cultural background.

Communication Techniques

At 55 years is the end of middle-aged adults and the beginning of older adults. That age is a vulnerable time in a person’s healthy life. Considering her place of dwelling, which is a high-density public complex, she may be going through severe social, economic challenges. Such difficulties would make her not easy to open up in most of the conversation (Deckx et al., 2015). Extracting information from a person undergoing such challenges can be quite difficult. At equal measure, it is also essential to provide such information with privacy. Therefore, as a clinician, I will be seeking to get the chief concern for her seeking health care services. If I find, she is not able to open up in the presence of family members, I would request them to step out of the clinic room for further engagement with the patient. I will start my conversation with the patient’s day to day activities.

I will always remember to respect her and gain her trust (Quinn & Gordon, 2015). When faced with silence, I have to recognize that too. However, I will try to figure out if her silence is out of anger, her economic situation, or if she is just unwilling to share. My objective will try to seek out in detail her concerns, by presenting genuine interest and curiosity towards addressing her concerns (Rosenberger & Lachin, 2015). I will use simple and understandable language and avoid any form of confrontation. I will listen keenly to what the patient says. Once I determine the principal concern, I will go on to discuss other sensitive health issues based on the information I gather from her.

Risk Assessment Instrument/Tool

Knowing that older adults have many health risks, and because assessment must be individualized multiple assessment tools will be necessary. I would use self- report information and the clinician-rated scales. The clinician-rated scale will help to conduct a clinically first diagnostic test. The clinical examination will be useful in narrowing down the patient’s conditions and results in proper medication. Besides, patient medical history will help in determining the most appropriate diagnosis (Wright, Tobias & Hickman, 2017). Even though HEEADSSS is for assessing adolescents, I would use it to determine her home environment, employment, eating pattern, and her other daily activities. This assessment tool will play a fundamental role in undertaking the most appropriate diagnosis.

Questions that I would ask

• How are things at the place of residence?  In terms of pollution from area residence or industries around?
• How old are you?
• What type of occupation do you do?
• What do you expect from this medical visit?
• Have you taken any medication in the recent past? And if yes what was it?

• Do you involve yourself in physical exercise?

Such open-ended questions will enable my patient to open up and talk more about areas that are troubling her.

References.

Aranda, J. P., Davies, M. L., & Jackevicius, C. A. (2019). Student pharmacists’ performance and perceptions on an evidence-based medicine objective structured clinical examination. Currents in Pharmacy Teaching and Learning, 11(3), 302-308.

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241-x

Quinn, L., & Gordon, J. (2015). Documentation for Rehabilitation-E-Book: A Guide to Clinical Decision Making in Physical Therapy. Elsevier Health Sciences.

Rosenberger, W. F., & Lachin, J. M. (2015). Randomization in clinical trials: theory and practice. John Wiley & Sons.

Wright, L., Tobias, S. M., & Hickman, A. (2017). Coding and Documentation Compliance for the ICD and DSM: A Comprehensive Guide for Clinicians. Routledge.

What’s Coming Up in Module 2?

In Module 2, you explore the impact of functional assessments, diversity, and sensitivity in conducting health assessments. You also examine various assessment tools and diagnostic tests used to gather information about patients’ conditions and examine their validity, reliability, and impact in conducting health assessments.

Next week, you will specifically examine functional assessments as they relate to diversity and sensitivity

Registration for Shadow Health

Throughout this course, you will participate in digital clinical experiences using the online simulation tool Shadow Health. The Shadow Health digital clinical experience provides a dynamic, immersive experience designed to improve nursing skills and clinical reasoning through the examination of digital standardized patients. Using Shadow Health you will participate in health histories, focused exams, and a comprehensive assessment.

There will be four Shadow Health assessment components that you will need to complete in Module’s 2 and 3:

• Health History Assessment (Week 3 & 4)
• Focused Exam: Cough (Week 5) for a pediatric patient presenting with cough
• Focused Exam: Chest Pain (Week 7) for an adult patient presenting with chest pain
• Comprehensive (Head-to-Toe) Physical Assessment (Week 9)

Before you can participate in these simulations, you will need to register for a Shadow Health account. To do this:

• Go to the Walden Bookstore and purchase access to Shadow Health and the required texts.
• Once Shadow Health has been purchased, an access code will be emailed to you from the bookstore.
• Review this video explaining how to register in Shadow Health: https://vimeo.com/275921826/c12d50ee6e
• Use the Shadow Health link located in the navigation menu on the left in the Blackboard course.
• Follow the prompts to register in Shadow Health. You will need the access code provided from the bookstore to register. Once registered, Shadow Health should always be accessed via the link in Blackboard.
• Use only Google Chrome when accessing Shadow Health and make sure all other programs are turned off on your computer. Other browsers do not work well and will not allow the Shadow Health speech to text function to work.
•  Once registered, complete the Shadow Health Orientation in the Shadow Health website/program and review the videos designed to assist with navigating and completing assignments.
• Read the Shadow Health Nursing Documentation Tutorial located in the Week 1 Learning Resources.

Note: As nurses you typically use the word assessment to mean completing the physical exam. However, in the SOAP Note format, assessment means diagnosis so start getting in the habit of calling the physical exam exactly that.

Week 2 Case Studies

In Week 2, your Instructor will assign you a case study related to your Discussion by Day 1 of the week. Please make sure to review the “Course Announcements” area of the course to verify your assigned case study. Please plan ahead to ensure you have time to review your case study and your Learning Resources so that you can complete your Discussions and Assignments on time.

Practicum – Upcoming Deadline

In the Nurse Practitioner programs of study (FNP, AGACNP, AGPCNP, and PMHNP) you are required to take several practicum courses. If you plan on taking a practicum course within the next two terms, you will need to submit your application via Meditrek .

For information on the practicum application process and deadlines, please visit the Field Experience: College of Nursing: Application Process – Graduate web page.

Please take the time to review the Appropriate Preceptors and Field Sites for your courses.

Please take the time to review the practicum manuals, FAQs, Webinars and any required forms on the Field Experience: College of Nursing: Student Resources and Manuals web page.

• Field Experience: College of Nursing Quick Answers
  
• Field Experience: MSN Nurse Practitioner Practicum Manual
• Student Practicum Resources: NP Student Orientation

Next Module

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