XH3003 Assignment Health History Across the Lifespan

Competency Assessment:

When Taking a Health History Is a Challenge

Student Name:

Date:

Use this template to record your response to each avatar scenario at Neighborhood Clinic, the fictional community health center, as you address communication challenges and identifying priority information. Base your responses on the Mursion interactive media, Learning Resources, and other resources you identify to support your responses to the following questions. All responses should have evidence cited to support statements made in your document. Your completed document should be 4–5 pages plus a reference page.

Scenario 1: Health History for a Young Child

Archie, age 7, and his father, Gabriel Moore

Challenges in Gathering a Health History for a Young Child

Archie has a problem, and the first clinic visit is at the age of 7. This is because the nurse might have to struggle to get answers from Archie, as he might be ill, or he might be uncomfortable giving answers. The nurse is most likely to have a challenge when interacting with this child because he is in the clinic for the first time. Health information that the nurse has to obtain from Gabriel’s father presents some challenges in the process (Jarvis, 2023). It is also noted that Gabriel has a few moments where his concentration is not on the highest standards, but this may be due to his concern for Archie’s health status and, presumably, his lack of full access to his records. Under these circumstances, the nurse must obtain all the facts and then verify them.

Communication Skills Needed by the Nurse

The nurse and/or talker will speak in simple English to allow questions to be understood by Archie and Gabriel. The nurse must follow the direction of the pointing, and Archie must be taught to point at the site of the injury. A nurse should simplify his or her words and not bring in so many medical terms. The nurse should use emotional intelligence and empathy in this instance (Perry & Hockenberry, 2022). The nurse should comfort Archie and show him that they understand that he is in pain by saying things such as “I see that you are sick and we will make you well.” The nurse should make sure that the nurse’s attention is on Gabriel and that he is comfortable and willing to take the interview in a quiet area from the conversation with Gabriel. So, in this instance, a soft tone makes Archie feel relaxed, as well as easing him into some minor decision-making about temperature checks.

Goals in Obtaining a Health History

We want to get comprehensive information about Archie’s health status, particularly about the symptoms and how they developed from the beginning. I have to get some fundamentals about Archie’s medical history, any allergies, medications he’s on, any pre-existing conditions, etc. With Archie and Gabriel, we’re looking to build trust in the task. Therefore, patients will receive assistance to give accurate information that is vital to establishing their treatment program.

Priority Information to Obtain

I need to know what symptoms Archie has now and the amount of time that these symptoms have been present. I want to know if Archie has had any diseases recently, if he has changed his diet, or changed any of his activities (Perry & Hockenberry, 2022). The nurse should record Archie’s current health state, any previous illnesses that he has had,d and the allergies he suffers from. His previous immunization record and the family medical history would need to be known to determine what might be wrong with his health condition.

Next Steps for Making a Health Assessment

The nurse will have to assess Archie physically to evaluate his physical health and signs. How Archie goes about it and how he responds to the physical checks gives an insight into what is causing him his symptoms (Jarvis, 2023). If Archie doesn’t feel like playing with the nurse or if he doesn’t want to play with the nurse, the nurse should change his activity to one he likes or remove the nurse for a few minutes to help Archie calm down. The nurse has to explain all the significant points to Gabriel and suggest further actions, such as further tests and therapies. The nurse should also record all information and be able, in a friendly way, to explain the care plan to Gabriel so that he/she can know what to do next.

Scenario 2: Health History for an Adolescent

Jasmine Walker, age 14

Challenges in Gathering a Health History for an Adolescent

Problems that may arise in collecting an adolescent’s health history.Issues that may arise during the process of obtaining information about an adolescent’s health history.
Jasmine Walker visits the high school clinic without her mom. Of course, the first time that Jasmine tries to answer questions by herself, she’s feeling uneasy. Due to this, adolescents feel sensitive about the issues they are willing to discuss in group forums, and they rarely disclose personal issues such as mental health issues or substance use. Since she had always consulted her mother regarding health matters, Jasmine had to discuss her health with her (Qureshi et al., 2023). Encourage Jasmine to talk about her emotions about the care she received without her mom.

Communication Skills Needed by the Nurse

The nurse should be frank and empathetic while talking to Jasmine so that she does not feel uncomfortable during the conversation. It’s important to listen actively. The nurse has to say: “I will support you for all that you need.” Please do not hurry while answering any questions I may have for you. The nurse should educate at the patient’s level and not use medical jargon that the patient won’t comprehend. A nurse must have emotional intelligence to manage his or her emotions as well as his or her patient’s emotions, which is the first requirement. What the bad things were that they said to Jasmine should be identified, and how they made her feel should be known by the nurse (M. Barch, 2021). The nurse should assure Jasmine that it is alright not to have a full understanding because she will be solving it with them. The nurse needs to be able to build up the trust of Jasmine by explaining to her that nothing she is asked to do will be shared. However, when the nurse tells Jasmine that all she tells her will be kept confidential, then the nurse can now encourage her to open up, with the exception of her patient being in danger.

Goals in Obtaining a Health History

So our primary purpose is to help Jasmine voice her opinions about her health problems, as her mother would not be there. The nurse needs to be aware of the physical and mental condition of the patient, social activities, and the current health issues. I want to be able to play my part in helping her to achieve self-responsibility in managing her health (Qureshi et al., 2023). I should tell her why it’s beneficial to provide accurate information and be involved in her health care.

Priority Information to Obtain

The nurse will have to get some information regarding Jasmine’s health issues, both now and in the past, and then check Jasmine’s vaccination record for a physical exam at school. I have to check for her activity and what she’s eating, in terms of food, to see if she is growing at the rate she should. This is a time of life where there are multiple transitions happening, and there is stress and tension, so it’s important to test for emotional wellness. You should ask her questions about her social life, school, and drug and alcohol use (among other things) during a health assessment.

Next Steps for Making a Health Assessment

The case calls for the nurse to thoroughly assess Jasmine to consider her health and if she is physically eligible to attend school. The nurse should notice the physical signs of distress in Jasmine, and must notice through non-verbal communication when conducting the physical examination. Therefore, to complete the missing details, the nurse should use more questions in a relaxed and natural conversation. Then the nurse asks, “Is there anything else that you would like to talk about at the moment?” for Jasmine to speak her mind during the shooting process (M. Barch, 2021). The nurse should make sure that she tells Jasmine the right health information, which is appropriate for her age, so that she will have better responsibility for her health. I will ensure that she has a healthy diet and exercise plan, will give her psychological support if needed, and will teach her to request it.

Scenario 3: Health History for an Older Adult

Colleen Hart, age 76

Challenges in Gathering a Health History for an Older Adult

It’s always difficult to get Colleen’s approval to come over for our meeting with her stepson. The final part of her power dynamics is when she is uncertain about revealing her health status to him. In dealing with this particular situation, the nurse has to respect Colleen’s rights to privacy and obtain the correct information on her health. The nurse should have full access to attend the meeting (Sharkiya, 2023), as should Colleen. She may have this fear because she is voluntarily giving up her part of decision-making concerning her treatment. She suffers from memory problems and other health problems, and she is embarrassed to go into detail about her health problems.

Communication Skills Needed by the Nurse

When explaining the findings to the nurse, Colleen anxiously asked about her stepson, and therefore, the nurse should use both verbal and non-verbal communication when talking to her. The second intervention is to respect Colleen’s right to privacy while saying to her, “I understand that you would like to have a private talk,k and I would like to assure you that you feel comfortable in this consultation.” This can be seen through how the nurse shows she does care about Colleen’s best interest, and more so as a patient. (Zhao et al., 2022) That means listening well, asking open-ended questions, and using body language to gain patient confidence. In this case, the nurse has to be emotionally intelligent and include the stepson while respecting the autonomy that Colleen has over her decision. The nurse should ask the stepson to participate only if it is necessary, and explain to Colleen why his participation is important.

Goals in Obtaining a Health History

The main aim of care is to obtain as much information as possible about Colleen’s health condition and to respect her choice as an adult. I need to know her medical record, her health record from before, and her daily life (Sharkiya, 2023). To assist Colleen in expressing concern, participating in the healthcare decision-making process, nd providing a safe setting. We aim to involve the stepson in the decision-making and to make sure Colleen’s right to privacy is respected. Must be on good terms with all individuals to develop a good working relationship with them.

Priority Information to Obtain

Details Colleen needs include her symptoms, long-term health concerns, current medications, and changes in health. Screening her psychological condition is important since many older adults are experiencing anxiety and depression, as they will not accept assistance in meeting their needs. I need to know what Colleen’s normal day is like, what she eats, how she sleeps, and how she moves her body to know her general health (Zhao et al., 2022). You may need to ensure that she can cope at home and determine if she has difficulties with housekeeping or if she is prone to falling.

Priority Information to Obtain from the Stepson

The nurse has to elicit some crucial information from the stepson during the appointment since Colleen may not remember or want to discuss such issues. Also, details of how she takes her medication and any behavioural changes will be needed, as well as a description of how she uses daily items. It is crucial to determine how the stepson sees the stepson’s home care situation and what dangers he sees as being present. Hence, the nurse must keep her professional attitude and act for Colleen’s needs. Some time needs to be dedicated to explaining it to her, to make her understand that this is a must, so that she does not start arguing, and to gain her confidence.

Next Steps for Making a Health Assessment

While assessing Colleen, the nurse has a physical examination to conduct and, at the same time, assess how well the patient is mentally. Firstly, the nurse needs to tackle a variety of health concerns and maintain documentation of all the findings. The nurse should honor Colleen’s privacy preferences by explaining to her the other ways in which she might obtain that information during the private session or at her next appointment. Therefore, it is essential to establish a care plan with Colleen and make sure she is a valuable employee and appreciated.