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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:

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.

Colleague 2

Case study

The assigned patient is a 38 years old Native American pregnant woman living on a reservation.

Summary of the interview

The assigned patient is a 38 years old Native American pregnant woman living on a reservation. Every patient should be treated as an individual, which is best achieved by building rapport. According to Ball et al. (2019), the first meeting with the patient is imperative to develop a successful partnership. Therefore, I would explain my primary purpose, which is to help her achieve her goals of a safe, healthy pregnancy and childbirth, as well as the hope of holding her baby in her arms for the first time. Also, explain that this can only be achieved by working together and being honest with each other. This promotes a feeling of safety, comfort, and alleviating nervousness, which enables the patient to be more relaxed in discussing her care.

It is necessary to consider the patient’s cultural beliefs and customs, which promotes a positive relationship built on respect, honesty, comfort and is essentially helpful in planning culturally sensitive care. When planning care for this patient, their traditional family organization must be considered, and the roles that women and children play in this culture are essential. Life on most reservations may include up to three-generation extended families living in one household or next to each other. Therefore, it is also important to discuss whom she would like to include in her care and what traditions she would incorporate. It is common for grandparents or close elders to care for the infant (Seideman et al., 1996).

The most important information to obtain is the date of her last period, to calculate the age of the pregnancy and if this is her first pregnancy. This is the patient’s second pregnancy, and she is in her first trimester. The next part of the interview is to find out if it was a normal vaginal delivery, if her baby was full term, and if she had any complications such as hypertension and diabetes during her pregnancy. Also, a thorough medical and surgical history is obtained, and a physical assessment to identify any problems that can complicate her pregnancy and establish a knowledge base.

The patient’s age also presents a potential health-related risk. The patient is 38 years old and is at risk for developing complications in her pregnancy. Advanced maternal age is associated with low birth weight, decreased APGAR scores, genetic disorders, hypertension, and gestational diabetes. Therefore, it is critical to emphasize the importance of closely monitored care during the length of her pregnancy. This will help the provider identify and treat any issues as early as possible (Sydsj? et al., 2019). Native American women living on a reservation are less likely to have access to quality prenatal care. 12% of Native American women reported not receiving quality prenatal care until the third trimester, which is the highest rate of any group of women in the U.S. Also, living conditions on the reservations are overcrowded due to housing shortages and are substandard. Lack of utilities and transportation to healthcare facilities increases the potential for health risk, especially in rural and remote areas where there is a lack of accessible healthcare (Reddy et al., 2021).

Description of the communication techniques

Effective communication has been proven to lead to successful patient-provider relationships and enhance patient outcomes. For a successful interview, there must be effective communication. One technique that I would utilize is the “patient-centered approach.” The patient-centered approach helps the provider obtain an in-depth understanding of the patient’s background and to establish a relationship between patient and provider. This type of interview provides open-ended questions, ample time for patients to answer questions, and encourages them to elaborate on their concerns (Ball et al., 2019). Other essential communication techniques are active listening and incorporating the patient’s cultural beliefs when communicating. For example, your tone of voice, eye contact, and body language are all ways of showing respect when communicating. In many Native American cultures, a direct eye contact is a form of disrespect. The eyes are believed to be the window to the soul. In order to avoid inadvertent soul loss/theft, eye contact may be avoided (Understanding Cultural Diversity in Healthcare, 2021).

The risk assessment instrument

According to Ball et al. (2019), all female patients should be routinely screened in all healthcare settings. According to the Centers for Disease Control and Prevention (2002) and the U.S. Institute of Medicine (2006), the “very low birth weight” rates (VLBW) and preterm births are higher among Native Americans. They are associated with lack of prenatal care, alcohol consumption, and smoking during pregnancy. I would utilize the CAGE (Cut, Annoyed, Guilty, and Eye) questionnaire to screen for alcoholism. CAGE is an acronym for the focus of the questions. This simple risk assessment tool should be utilized on every patient to screen for alcoholism (American Addiction Center, 2021).

Another risk assessment tool I would utilize for this patient is the HITS (Hurt, Insult, Threat, or Scream), a screening tool used to screen patients for domestic violence. (Ball et al., 2019). Studies have shown that approximately 36% of women who experience domestic violence at some point in their lives are too scared, embarrassed, and nervous to “speak up” when being abused. The HITS screening tools is essential because it is one of the best ways to detect domestic violence and provide referrals to resources for victims, preventing severe mental and health effects and even life-threatening situations to both the mother and child (American Family Physician, 2019). As a healthcare provider, the health and safety of my patient is my priority. Women abused during pregnancy are more likely to be depressed, suicidal, and experience pregnancy complications and poor outcomes, including maternal and fetal death.

Five Target Questions

Is this your first pregnancy?

Did you have any issues such as hypertension, diabetes, bleeding or depression with your previous pregnancy?

Do you have any concerns about this pregnancy whether they be financial, mental or physical?

Are there any genetic disorders in you or your husband’s family?

Are you taking any medications- prescribed, over the counter, supplements, vitamins, and/or traditional remedies?

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