Health history | NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning | Walden University

The scenario I will be writing on is “A 14-year-old biracial male living with his grandmother in a high-density public housing complex”.

            Collecting patient data is a core step in the nursing process and healthcare professionals usually develop a relationship with their patients during the history and interviewing process ((Ball, Dains, Flynn, Solomon, & Stewart, 2019). I will first introduce myself to the patient and establish privacy. When interviewing the patient effective communication is important. It is necessary to establish a positive patient relationship by ensuring courtesy, comfort, connection, and confirmation.

          Teenagers are exposed to many external and internal struggles and are expected to cope with hormonal changes, puberty, social and parental forces, work and school pressures, and other problems of life. During adolescence, individuals may also be exposed to risky behaviors and need help in making the right decisions. As such, teenagers may be unwilling to speak with healthcare providers. There is, therefore, the need to establish privacy and providers must be sensitive to the needs and situation of the patient. Providing a safe place for the adolescent to speak freely is a goal of the healthcare provider (Ball et al., 2019). 

            The health assessment will be from head-to-toe and going through each system of the body. During the interview process, I will ask the patient open-ended questions regarding his health, to allow him to share more information, including his feelings, attitudes, and understanding of the subject. Examples of open-ended questions that may be asked to a 14-year-old include; 

Tell me about your living situation, and how are things at home?
Tell me about your friends, and what activities do you do with your friends?
What do you like or don’t like about your school?

          Risk assessment explores the behavioral and lifestyle changes and influences decisions regarding treatments (Wu & Orlando, 2015). Specific screening tools have been developed for gathering the psychosocial history of adolescents (Sullivan, 2019). The screening tool for adolescent issues is the Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety (HEEADSSS). This interview format is flexible and designed for adolescents because physical and social threats are common during adolescent age.

References

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.

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

Wu, R. R., & Orlando, L. A. (2015). Implementation of Health Risk Assessments with Family Health History: Barriers and Benefits.” Postgraduate Medical Journal, no. 1079: 508. doi:10.1136/postgradmedj-2014-133195.