Building a Comprehensive Health History, NURS 6512

Building a Comprehensive Health History, NURS 6512 Building a Comprehensive Health History, NURS 6512 ORDER NOW FOR CUSTOM, PLAGIARISM-FREE PAPERS ON Building a Comprehensive Health History, NURS 6512 Upon establishing a relationship and building a comprehensive health history, one must understand the importance of a thorough history document. This document is often used as the basis for the entire course of medical management for a patient (Sullivan, 2012). Everyone has a story, and the heath history document should paint an up-to-date and accurate account of the patient’s medical history and a comprehensive physical examination. Any professional that reads the health history document should have a good overview of that patient. According to Ball, Dains, Flynn, Solomon, & Stewart (2015), the initial meeting between the clinician and the patient sets the tone in the relationship for success, allows the patient to voice concerns, identifies expectations for a good outcome, and to build a partnership in one’s health care. For this week’s discussion, the role of a clinician when building a comprehensive health history with a 16-year old white pregnant teenager living in an inner- city neighborhood will be identified. In addition, review of communication techniques and a risk assessment tool is used with five or more targeted questions that could be asked in this particular situation. 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, 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, 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). 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. 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., 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). 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). 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? 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. 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. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10