The Question

The Patient:

38-year-old Native American pregnant female living on a reservation

Please make sure that you answer all of the required info in your post:

· How would your communication and interview techniques for building a health history differ with each patient?

· How might you target your questions for building a health history based on the patient’s social determinants of health?

· What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?

· Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.

· Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.

· Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

READING RESOURCES

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.

· Chapter 1, “The History and Interviewing Process”

This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

· Chapter 5, “Recording Information”

This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

· Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0

Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015

Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238