Week 1: Building a Comprehensive Health History

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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.

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Patient Profile

The patient for this week’s discussion is a 16-year-old white pregnant female living in an inner-city neighborhood. No other information has been provided. This patient has scheduled an appointment with me, her nurse practitioner, for an evaluation.

Techniques for Creating a Health History

Allowing the patient to voice their concerns, describing their condition or illness in their own terms, and using this information from that patient’s perspective are facets that can build a precise health history. A thorough health history is the building block for an accurate physical exam of the patient. The techniques fundamental to constructing a comprehensive health history are establishing a connection with the patient, utilizing clear, age-appropriate and comprehensible communication, and allowing the patient to express themselves while being an active listener (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Creating a safe place, assuring confidentiality, establishing a connection, and asking questions that are open-ended, patient-centered, and age-appropriate are effective measures I would use to obtain an accurate, complete, and honest patient health history from this patient (Ball et al., 2019).

Framing the Questions: An Interviewing Strategy

Social determinants consisting of age, gender, economic and employment status, lifestyle, living situation, culture, genetics, and education can become obstacles in obtaining a detailed health history. Characteristics of social determinants can influence a patient’s attitude, impression, and trust in healthcare, subsequently impacting the patient’s overall health and deliverance of care (Gurewich, Garg, & Kressin, 2020). This patient is 16-years-old and is pregnant. My concerns surround her and her baby’s health, safety, available support systems, and sufficient and affordable resources.

After providing a safe and supportive surrounding and establishing a connection with this patient, I would allow this patient to share her story and her reasons for coming to see me. Patient-centered communication is vital during the collection of a patient’s health history. Questions need to be framed based on the patient’s level of health literacy, and social determinants need to be taken into consideration (Hong & Oh, 2019). Facilitating open-ended questions, proceeding with communication that is reflective of respect, clarity, and comfort, adapting language that is in accordance to the patient’s age and education level, demonstrating an understanding of the patient’s concern and complaint, reflecting on what the patient is saying, and repeating the patient’s statements as a confirmation to establish accuracy in what the patient has reported are successful components within the interviewing process that will assist in obtaining a thorough health history (Ball et al., 2019). Presence and support are the essences that will connect a practitioner’s knowledge and expertise to be successful in forming a trusting relationship with this adolescent.

Questions I would ask this patient would be about her present condition. I would have her tell her story, who she is, her current state of health, and if she is experiencing any symptoms that may be related to her current health condition or the pregnancy. If so, I would have this patient discuss with me in her own words, the location, description, duration, intensity, and any alleviating or aggravating factors. I would ask about her past medical history, including immunizations, current medications, previous surgeries, disabilities, allergies, recent medical or prenatal care, and emotional state. I would ask about her family history and any related diseases, the ages of family members, racial and cultural background, and support system. I would touch upon her personal and social history that would include her status as to ethnicity, gender identity, home environment, birthplace, education, sources of stress, diet, sleeping patterns, drug and alcohol use, tobacco use, self-care, and her sexual history. Such questions would consist of when did start having sexual intercourse, how many partners, has she used any birth control or prevention against sexually transmitted diseases when was her last menstrual period, had she been coerced into having sexual relations, when did she discover that she was pregnant? I would inquire about any religious practices or cultural customs that she practices. I would continue to ask about her access to medical care. In terms of her finances or insurance coverage, I would inquire if she had an occupation or any economic needs. At this point, I would conduct a review of all systems from head to toe. After my exam, I would provide an opportunity for this patient to add any additional information.

Using Risk Assessment Tools to Identify Health Risks

Risk assessment of patients allows providers to identify potential health hazards that may negatively impact the current or future status of a patient’s health. Identifying risks enables the clinician to analyze these probabilities and create appropriate strategies to prevent, control, or help eliminate the threat. As part of patient-centered and personalized precision medicine, risk assessment tools help identify patients that could be at a higher risk of developing a disease (Subramanian & Kattan, 2020). When the patient reports their family, personal, and mental health history, social preferences, prior or lack of medical care, and other social determinant factors, a more in-depth insight is revealed illuminating potential problems that the patient may be predisposed to developing or maybe unaware he or she already has. Using risk assessment tools can also highlight the patient’s strengths and weaknesses as to the comprehension of these hazards, compliance or noncompliance with medical care, likelihood to adapt to other measures to ensure quality treatment can be delivered and maintained, emotional liability, personal safety, and ability to access care. By using risk assessment instruments, as providers, a better and holistic understanding of the entire patient can be seen.

Health-Related Risks Identified in the Patient

This patient has the potential for many health-related risks, which could affect her health, but also her baby’s overall health. This patient’s living situation lies within an inner-city. Inner-city living can place a severe health hazard for this patient and her baby. This patient and her baby are prone to increased exposure to poor air quality from the presence of factories, cars, and climate, unsafe road conditions, crime, noise, and an increased risk of exposure to other potential health risks (World Health Organization, n.d.). A great example would be exposure to COVID-19, which placed significant stress on many inner-city neighborhoods.

As a city child myself, there are many facets to an inner-city. Depending on where she lives in an inner-city, she could be staying in a beautiful townhouse or residing in a neglected area where housing projects and lower-income housing are prevalent. Location in a city could be promising with a close bus route and nearby stores, clinics, and other resources. Other places may be on the bus route’s last stop; the area may be unsafe, and resources that once were there are now gone or have moved to a better neighborhood.

Other health-related risks one can surmise is poor nutrition, lack of adequate housing, loss of appropriate education, inability to obtain employment, absence of familial support, high risk for acquiring a sexually transmitted disease, inadequate prenatal care, exposure to violence, opportunities to indulge in drug, tobacco, or alcohol use, compromised mental well-being, financial concerns, risks of insufficient post-natal care, high probability for delivery complications and the birth of the baby, and an increase in the potential for medical and developmental complications of the baby. Children born to adolescent mothers tend to have poorer health, adverse birth outcomes, and cognitive and developmental disorders (Bretz, Beharry, Mallett, Virani, & Whiteis, 2020).

One Risk Assessment Tool that Would be Used for this Patient

The case presentation is very vague; however, adolescents may choose not to disclose such information, which will impede a thorough health history. Adolescence is a sensitive and trivial time for many young women and men as they transition from childhood to adulthood. There are significant changes to the body, but also in their relation to the world. Health disparities and social determinants still exist and contribute to high teen birth rates (Centers for Disease Control and Prevention, 2019).

One risk assessment tool I would use for this patient is the pneumonic HEADSSS, which is a simple evaluation tool that focuses on the home environment, education, employment, eating, activities, drugs, sexuality, thoughts of suicide, depression, and safety (Ball et al., 2019). This screening tool allows the practitioner to get a sense of the context of a teenager’s life. Another risk assessment tool, that caught my attention, is known as KINDEX. KINDEX is a prenatal risk assessment instrument that helps to identify areas of stress, trauma, and other psychosocial areas. This short tool identifies pregnant women who are in high-risk circumstances or environments that are experiencing elevated psychosocial experiences and allows clinicians to refer women to adequate mental health and social services, promoting a healthy family environment and child development (Spyridou, Schauer, & Ruf-Leuschner, 2015).

Five Targeted Questions

Open-ended questions that encompass understanding, compassion, and empathy can help facilitate a trustful and honest interview and develop a robust health history that will allow the provider to pinpoint the patient’s problem(s) and formulate a plan of care. Targeted questions will assist the direction of the interview and go deeper into the patient’s life, feelings, and perspectives. The questions I would ask this patient are as follows:

What concerns do you have regarding your current health and your pregnancy that you would like to discuss today?
Do you have a support system in place and, if so, who is your support?
How do you feel about this pregnancy?
What are your plans for this pregnancy?
Based on the questions above, I would ask this question. As your provider, what resources do you need that will support your decision? Together, we can explore options and opportunities.

References

Ball, J., 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

Bretz, L. A., Beharry, M., Mallett, L., & Whiteis, A. (2020). Health outcomes in a “Teen Tot” clinic: A retrospective cohort study. Journal of Adolescent Health, 66(2), S99. doi: 10.1016/j.adohealth.2019.11.199

Centers for Disease Control and Prevention. (2019). Social determinants and eliminating disparities in teen pregnancy. Retrieved from https://www.cdc.gov/teenpregancy/about/social-determinants-disparities-teen-pregnancy.html

Gurewich, D., Garg, A., & Kressin, N. R. (2020). Addressing social determinants of health within healthcare delivery systems: A framework to ground and inform health outcomes. Journal of General Internal Medicine, 35, 1571-1575. doi: 10.1007/s11606-020-05720

Hong, H., & Oh, H. J. (2019). The effects of patient-centered communication: Exploring the mediating role of trust in healthcare providers. Health Communication, 35(4), 502-511. doi: 10.1080/10410236.2019.1570427

Spyridou, A., Schauer, M., & Ruf-Leuschner. (2015). Obstetric care providers are able to assess psychosocial risks, identify and refer high-risk pregnant women: Validation of a short assessment tool- the KINDEX Greek version. BMC Pregnancy and Childbirth, 15(1), 41. doi: 10.1186/s12884-015-0462-y

Subramanian, V., & Kattan, M. W. (2020). Clinical risk assessment and prediction. In Adam, T., & Aliferis, C. (eds.) Personalized and Precision Medicine Informatics. Health Informatics. Springer. doi: 10.1007/978-3-030-18626-5_2

World Health Organization. (n.d.). Addressing the social determinants of health: The urban dimension and the role of local government. Retrieved from https://www.euro.who.int/_data/assets/pdf_file/0005/166136/UrbanDimensions.pdf?ua=1

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COLLAPSE
Pre-school aged white Female living in a rural Community

This discussion is about a pre-school aged white female that lives in a rural community. Pre-school age is between 3-6 years old, and communicating with this age group can be challenging. As such, a specialized and effective form of communication or interview has to be utilized to elicit the best response.

Communication Techniques

Communication techniques used for this age group include talking, listening, and simple language (Ball, Dains, Flynn, Solomon, & Stewart, 2019). Preschoolers are known to be chatty, which can be the first step in building trust and a relationship. Additionally, letting the child sit close or on their parent’s lap adds comfort and security, which in turn calms fears and anxiety (Ball et al., 2019). However, it is best and appropriate to gather history from the parent or a responsible adult due to the child’s age. Researchers are reluctant to enroll children capable of communicating along the lines of the traditional data collection methods (Underwood, Chan, Koller, & Valeo, 2015).

Risk Assessment Instruments

The risk assessment tool that I will use is the Parenting Stress Index short form (PSI-SF). The first version PSI questionnaire tool developed in 1983, it helps to identify stressors in parent-child interaction and can be used with parents and children ages one month to 12 years old. This measure helps to evaluate family dynamics and the parent-child relationship. This tool focuses on the three main domains of stress, which include the child and parent characteristics with situational/demographic life stressors (American Psychological Association [APA], 2020). As we know, stress can affect parent-child relationships in a negative way. Stress is characterized as adapting to difficulties and influencing parenting, which can then manifest with children exhibiting behavioral problems between the ages of 3 to 9. So, given the stress related to parenting, an assessment tool like the PSI is a valid measure of parent-child dysfunctional relationships (Barroso, Hungerford, Garcia, Graziano, & Bagner, 2016). A typical stress score falls between 15 and 80; high stress ranges from 81 to 84and stress level above 85 will need additional follow up.

Targeted Questions

The first thing I will do is consent from the parent/caregiver/responsible adult before proceeding to ask the child some questions. Once consent is given, I cautiously begin to pose the questions to the child as follows:

What is your name?
How old are you?
Who brought you to the clinic today? (referring to the parent).
Do you have a favorite game/toy?
What part of your body is hurting?
It is essential to know the patient’s age to know how to word the questions. We should give the child the chance to talk (if capable) and not let adults replace it. Although they are young, an adult cannot accurately describe the child’s experience of pain (Underwood, Chan, Koller, & Valeo, 2015).

References

American Psychological Association (APA). (2020). Parenting Stress Index. https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/parenting-stress

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.

Barroso, N. E., Hungerford, G. M., Garcia, D., Graziano, P. A., & Bagner, D. M. (2016). Psychometric properties of the Parenting Stress Index-Short Form (PSI-SF) in a high-risk sample of mothers and their infants. Psychological assessment, 28(10), 1331–1335. https://doi.org/10.1037/pas0000257

Underwood, K., Chan, C., Koller, D., & Valeo, A. (2015). Understanding Young Children’s Capabilities: Approaches to Interviews with Young Children Experiencing Disability. Child Care in Practice, 21(3), 220–237.

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