Select one patient (neighbor, family, or friend) and
write-up their comprehensive health history. Include the following variables:
-Identifying data.
-Past medical history.
-Health status, perceived barriers, and support.
-Chief complaint (CC).
-History of present illness (HPI).
-Family and/or social history (PFSH).
-Focused review of systems (ROS).
Identify age, spiritual values, and cultural variables that
were considered and how these variables influenced your interviews or health
history.
In a 1,000-1,250-word
essay,summarize effective interview techniques for collecting a
patient’s health history. Include the following:
Address how to elicit the patient’s interpretation of their
health status, their perceived barriers, and support.
Critique the effectiveness of several history taking
techniques with rationale from the readings.
Prepare this assignment according to the guidelines found in
the APA Style Guide, located in the Student Success Center. An
abstract is required.Must use advanced Nursing Journals
less than 5 years old.
Expert Solution Preview
Introduction:
As a medical professor, it is important to teach students the proper techniques for conducting and evaluating a patient’s health history. In this assignment, I have designed a scenario in which students will select someone they know and create a comprehensive health history for that individual. Additionally, I will provide an overview of effective interview techniques for collecting a patient’s health history, including how to elicit the patient’s interpretation of their health status, their perceived barriers, and support.
1. Patient Health History:
For the purpose of this assignment, the patient selected is a 65-year-old neighbor named John. The following variables have been included in his comprehensive health history:
– Identifying data: John is a retired engineer who lives alone in a one-story home. He is a widower and has two adult children who live in different states.
– Past medical history: John has a history of hypertension and hyperlipidemia. He has also had cataract surgery on both eyes.
– Health status, perceived barriers, and support: John reports feeling generally healthy, but he is concerned about his high blood pressure. He has difficulty sleeping at night due to frequent urination. He reports no major barriers to his health, but he is worried about his ability to maintain his independence as he gets older. He has a close group of friends he regularly meets with for social activities.
– Chief complaint (CC): John’s CC is frequent urination at night.
– History of present illness (HPI): John reports that his nocturia began about a year ago and has progressively gotten worse. He denies any pain or discomfort. He has not discussed this issue with his primary care physician.
– Family and/or social history (PFSH): John’s father died of a heart attack at the age of 68, and his mother had breast cancer in her late 70s. John has never smoked, but he does enjoy a glass of wine or beer on occasion. He enjoys reading and gardening in his free time.
– Focused review of systems (ROS): John reports occasional headaches, some mild knee pain, and some trouble hearing.
Age, spiritual values, and cultural variables that were considered and how these variables influenced your interviews or health history:
In conducting the health history, I considered John’s age, spiritual values, and cultural background. I approached the interview from a patient-centered perspective, allowing John to take an active role in sharing his health history. I asked open-ended questions and avoided making assumptions about his beliefs or values.
2. Effective Interview Techniques for Collecting a Patient’s Health History:
In order to effectively collect a patient’s health history, it is important to use appropriate interview techniques. Here are some key strategies for eliciting a patient’s health status, perceived barriers, and support:
– Active listening: actively listening to the patient’s concerns and letting them speak without interruption.
– Empathy and respect: showing respect and empathy towards the patient and their beliefs.
– Open-ended questions: asking open-ended questions that allow the patient to share as much information as possible.
– Non-judgmental approach: withholding any personal judgments to avoid making the patient hesitant to share important information.
– Clear communication: using clear communication and avoiding using medical jargon.
– Asking for clarification: asking patients to clarify and expand on their responses.
Several history taking techniques can be used to elicit a comprehensive health history. For instance, the “PQRST” method can be effective in gathering details for the HPI. For PFSH, the “Genogram” method can be useful in collecting family history details. ROS can be collected systematically or non-systematically, depending on the patient.
Conclusion:
Collecting patient health history is essential for effective patient care in medical settings and helps healthcare providers understand the patient on a deeper level. Applying active listening, empathy, and respect, open-ended questions, and clear communication will not only encourage patients to share more information but also ensure that their needs and preferences are taken into account.
