NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY
- Case B 85 year old white female living alone with no family in declining health
- Case C Adolescent white male without health insurance seeking medical care for STI
- Case E Adolescent Hispanic/Latino boy living in a middle-class suburb
- Case G 4 year old African American male living in a rural community
For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient (above) assigned by your Instructor.
With the information presented in Chapter 1 of Ball et al. in mind, consider the following:
- By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
- How would your communication and interview techniques for building a health history differ with each patient? NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY
- 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.
BY DAY 3 OF WEEK 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
The case study analysis assigned to me involves an 85-year-old white female living alone with no family who is in declining health. In expanding upon the case study, I utilized the SOAP note format, which is presented below:
Subjective (S): JD is an 85-year-old white woman who presents to the emergency department with concerns about declining health due to multiple falls and pain in the left hip. The falls began about a year ago and have increased in frequency and severity in the past three months. The most recent fall was today when the patient fell while getting up to use the bathroom, and she fell to the floor and landed on her left side. She immediately called 911. She states that pain in the left hip increases with weight-bearing activities, and she has been unable to put weight on the left side. She has not taken anything for the pain. She states that pain is 10/10 with any weight-bearing or ROM activities. She does not use any assistive devices for mobility. She eats one meal daily and tries to have a Boost supplemental shake daily. Patient has intermittent urine incontinence. She does not have relatives or friends available to assist her. She still drives, though she avoids driving at night.
She has a history of osteoporosis, hypertension, dyslipidemia, anxiety, and depression. Her medications include: metoprolol tartrate 50 mg twice daily, atorvastatin 20 mg daily, sertraline 50 mg daily, multivitamin daily, and vitamin D3 25 mcg daily NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY.
Objective (O): JD is an older white woman who appears frail, malnourished, and anxious. Alert and oriented x 3. VS: 143/94, P 101, RR 20, 97% on room air at rest, and T 97.8F. Weight 91 pounds and height 5’1”. BMI is 17.2. Significant bruising was noted in the LLE from the lateral aspect of the hip that extends medially towards the groin and distally above the knee. X-rays demonstrate a left femoral neck fracture.
Assessment (A): 1.) Traumatic fracture of the left femoral neck 2.) falls 3.) malnourishment 4.) hypertension 5.) osteoporosis 6.) dyslipidemia 7.) anxiety 8.) depression.
Plan (P): Patient is being admitted to the hospital for immediate surgery for a traumatic left femoral neck fracture. Referral and transfer to orthopedics are planned. Patient was provided education on proper nutritional requirements and how to maintain a healthy weight via teach-back and literature. The provider had a conversation with the patient regarding the safety of living within her home, and the patient plans to return home accordingly. Patient is to follow up with the orthopedic surgeon, primary care provider, and cardiologist upon discharge. A discussion for plans to discharge from the hospital to a skilled nursing facility was had, and the patient agreed with this plan. Medication additions include: hydrocodone-acetaminophen 5-325 every 4-6 hours as needed. No medications were discontinued NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY.
Communication and Interview Techniques
Providers must efficiently use several communication and interview techniques with various populations. In this case study, the patient is an elderly 85-year-old woman. One study provides evidence that the elderly population does not tend to seek out emergency department care unless severe or life-threatening injuries occur (Lutz et al., 2018). She has no hearing or visual concerns; therefore, the provider does not need to make adjustments. The provider should position themselves near the patient with as few obstacles in between as possible (Ball et al., 2019). Maintaining eye contact, having an open posture, using appropriate non-verbal cues, and utilizing appropriate follow-up questions are necessary to gain the patient’s trust (Ball et al., 2019). Since the interview is occurring in the emergency department, the interview must be focused and timely. The provider should begin with open-ended questions to ascertain the patient’s chief concern and follow up with appropriate questions to gain the patient’s trust (Ball et al., 2019). Once rapport is developed and the patient is more at ease, the provider can ask more personal questions, such as about lifestyle and socioeconomic status (Ball et al., 2019). Questions should occur one at a time and in a manner that allows for the patient to respond fully before proceeding. Though the patient’s care will be transferred to the orthopedic surgeon, education should be provided to the patient. Since the patient is in a heightened emotional state, it is necessary to provide educational materials in the form of literature for the patient to reference later (Hoek et al., 2020). Keeping the patient informed at every step of care is imperative to ease the patient’s anxiety and ensure safe outcomes.
Risk Assessment Instrument
Several risk assessment instruments would be beneficial in this case study. A fall risk assessment tool is the most common and pertinent tool for the patient in this case study. A widely used tool is the Johns Hopkins Fall Risk Assessment Tool, which consists of 7 questions about age, fall history, elimination, bowel and urine, medications, patient care equipment, mobility, and cognition (Johns Hopkins Medicine, n.d.). Scores between 6-13 are a moderate fall risk, and greater than 13 points are a high fall risk (Johns Hopkins Medicine, n.d.). Patient in this case study is a high-fall risk as demonstrated by her age (85), fall in the past six months, incontinence, medications (antihypertensive, opiate), and impaired mobility NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY.
Another risk assessment tool that should be utilized in this case study should involve nutritional status. Significant evidence suggests that malnourishment is a risk factor for falls and should be addressed at every point of care (Adly et al., 2019). Since the patient in this case study is below the recommended BMI and only eats one meal/daily with the occasional supplemental beverage, it is necessary to provide extensive education to inform the patient of the importance of maintaining a healthy diet to prevent future falls and fractures. One of the most commonly used nutritional risk screening tools for the elderly is the Mini Nutritional Assessment Short-Form (MNA). The MNA includes various components such as loss of appetite, altered sense of taste and smell, loss of thirst, frailty, and depression, all of which are relevant in the older population (Reber et al., 2019). Information gathered from this tool allows for timely nutritional intervention. Maintaining an optimal nutritional status could lead to fewer falls.
Health Risk Interview Summary
- What is your past medical history?
- What is your living situation?
- Do you live alone? Have any relatives or friends that would be able to assist you?
- What obstacles within your home make it difficult for you to complete daily activities? Do you use an assistive device for mobility?
- Take me through a typical day.
- How many meals are you eating? What do the meals consist of?
- What are your bowel and urinary habits? Do you wake up at night to use the bathroom?
- Are you able to shower/bathe yourself? Do you use any assistive devices? Do you feel safe and steady when doing these activities?
- How do you manage your medications? Do you always take them as they are prescribed? How do you pick up your medications?
- How often do you fall in a week, month, or year?
- Is there a specific time of day when you fall? Is there a specific activity that you are doing when you fall? NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY
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
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.
Hoek, A. E., Anker, S. C., van Beeck, E. F., Burdorf, A., Rood, P. P., & Haagsma, J. A. (2020). Patient discharge instructions in the emergency department and their effects on comprehension and recall of discharge instructions: A systematic review and meta-analysis. Annals of emergency medicine, 75(3), 435-444. https://doi.org/10.1016/j.annemergmed.2019.06.008
Johns Hopkins Medicine. (n.d.). Fall risk assessment tool. Retrieved from https://www.hopkinsmedicine.org/institute_nursing/_docs/JHFRAT/JHFRAT%20Tools/JHFRAT_acute%20care%20original_6_22_17.pdf
Lutz, B. J., Hall, A. G., Vanhille, S. B., Jones, A. L., Schumacher, J. R., Hendry, P., … & Carden, D. L. (2018). A framework illustrating care-seeking among older adults in a hospital emergency department. The Gerontologist, 58(5), 942-952. https://doi.org/10.1093/geront/gnx102
Reber, E., Gomes, F., Vasiloglou, M. F., Schuetz, P., & Stanga, Z. (2019). Nutritional risk screening and assessment. Journal of clinical medicine, 8(7), 1065. https://doi.org/10.3390/jcm8071065
BY DAY 6 OF WEEK 1 – NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY
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
Additional Risk Factors
As you stated this patient has multiple risk factors. An additional risk factor for this patient would be risk for pressure injury (PI) (Elsorady & Nouh, 2023). Assessments could be completed using the Waterlow or Braden Scales, which both have high sensitivity for pressure injury risks (Elsorady & Nouh, 2023). Elsorady & Nouh (2023) stated that a body mass index (BMI) under 18.5 places a patient at risk for PI. Your patient with a BMI of 17 would be at risk of injury. Other factors include a frailty assessment including cognition and functional status (Elsorady & Nouh, 2023). McCance & Huether (2019) state that frailty is a state that follows a stressor (such as a fall) in which the patient is at increased risk of poor resolution of homeostasis. Frailty increases the risk of further adverse outcomes such as further falls, delirium, the need for long term care due to disability, and death (McCance & Huether, 2019). The patient is currently bedbound with a broken hip so functional status will be an issue for pressure injury prevention. Elsorady & Nouh (2023) highlighted the need for early intervention for PI prevention at time of admission.
You did highlight on the poor nutritional status of the patient. Malnutrition can occur in older adults hospitalized due to their acute illness and comorbidities (Dent et al., 2018). This patient will have time periods of nothing per oral or NPO due to need for surgery. Completing a nutritional screening can assist in prompting orders for a dietician consult (Dent et al., 2018). Dent at al. (2018) found that when the nutritional assessments were being completed upon admission, even if the result triggered a best practice alert for a nutritional consult, the consult was not being added to the patient.
Another assessment that should be performed for the patient is a delirium assessment (McCance & Huether, 2019). The population at greatest risk for delirium are hospitalized older individuals (McCance & Huether, 2019). Delirium can present as hyperactive, hypoactive, or mixed features (McCance & Huether, 2019). Hewitt et al. (2019) used the Confusion Assessment Method (CAM) scoring. They concluded that around 10% of acutely hospitalized patients with fractures developed delirium, which significantly lengthened their hospital stays (Hewitt et al., 2019). Interventions for delirium include early mobility, hydration, nutrition, pain management, sleep maintenance, and lastly pharmacologic therapy (McCance & Huether, 2019). Prevention is better than treatment though so early screening and nonpharmacologic interventions such as hydration and nutrition can have effective results in elderly patients (McCance & Huether, 2019).
Dent, E., Wright, O., Hoogendijk, E. O., & Hubbard, R. E. (2018). Nutritional screening and dietitian consultation rates in a
geriatric evaluation and management unit. Nutrition & Dietetics, 75(1), 11–16. https://doi.org/10.1111/1747-0080.12391
Elsorady, K. E., & Nouh, A. H. (2023). Biomarkers and clinical features associated with pressure injury among geriatric
patients. Electronic Journal of General Medicine, 20(1), 1–6. https://doi.org/10.29333/ejgm/12636
Hewitt, J., Owen, S., Carter, B.R., Stechman, M.J., Tay, H.S., Greig, M., McCormack, C., Pearce, L., McCarthy, K., Myint, P.K., &
Moug, S.J. (2019). The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome.
Geriatrics, 4(4), 57. https://doi.org/10.3390/geriatrics4040057
McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children, (8th ed.). Elsevier.
NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY Sample response 2
Thank you for your very thorough post on your assigned case study. You provided a great picture of the communication strategies you would use, the questions you would ask to compile an adequate health history, and the risk assessment instruments you would utilize. With the patient’s injury, I agree that it would appropriate for the patient’s environment to be as comfortable as possible. Keeping in mind how the room is arranged, including noise level, lighting, and temperature of the environment are all factors that should be considered to ensure the patient feels safe and secure. If the advanced practice registered nurse (APRN) can establish rapport with the patient early on, the interview process and physical assessment will go much smoother knowing the patient already has trust for the provider. The way the APRN communicates with the patient will determine the patient’s understanding and ability to comprehend their injury and overall plan of care. The quality of communication will also determine how well the patient responds and engages with the provider, therefore impacting the care the patient receives.
You had mentioned providing the patient with education in the form of literature due to the nature of the injury, however, it would also be important to consider how the patient prefers to be educated. In my current role as a registered nurse (RN), I am required to document a daily education assessment on each patient. One of the measures of education includes how the patient prefers to be educated whether that be through verbal, written, demonstrative, interpretation, or virtual methods. Every patient is different depending on the circumstances, including age, level of understand, and cultural barriers, so I do take this piece into consideration as I am educating my patients. In my own practice, I can agree that the elderly population is less likely to come to the hospital emergently unless their concern or injury is life-threatening. I find it interesting that there is gathered data on this trend, although I can see where this mentality can lead to a delay in care.
The risk assessment instruments you have provided are something I am familiar with, especially the John Hopkins Fall Risk Assessment Tool. I use this tool on every patient I care for as it truly is a great indicator for patient safety. This data is often communicated with collaborative staff such as our therapy staff (physical therapy, occupational therapy, and speech therapy) and case management, while it is utilized in our world as an indicator to put safety measures in place as soon as possible. You have to think that falls happen at home, but they also happen inpatient as well. Knowing this patient had a fall at home, puts them at further risk of falling in the hospital due to potential delirium, medication side effects, stimulation, inadequate sleep, and so on. Tyndall et al. (2020) adds the “mean additional length of stay per inpatient fall was estimated to be eight days and mean additional financial cost was $6669 per fall in six hospitals in Australia” (para. 7). Beyond the injury comes cost where both factors remain a concern for all parties involved. In knowing this data from a supported study, it shows why risk assessment instruments are so vital for patients, providers, institutions, and organizations to utilize them appropriately.
I also appreciate your mention of a nutritional risk assessment as this is one area that I feel gets overlooked in practice. A patient’s nutritional status is a huge indicator of what is going on with the patient physically, including relatable injuries and declining health trends. Nutrition is such a huge part of anti-aging, mobility, chronic illness, sleep, recovery, hydration, healing, cognitive function, and more. I have cared for a large population of patients in the intensive care setting that fallen victim to horrific falls and injuries due to malnourishment and dehydration. According to Hamrick et al. (2020), there is a strong association between dehydration and falls which is why addressing these risks “has potential for improving quality of life for patients as they age” (para. 4) NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY.
The target questions you have listed, especially the question in relation to falls, were comprehensive. In my own experience, many of the patients I have cared for write off falls as a normal part of aging although many of these trends often times lead to other undiagnosed conditions or concerns. Gathering fall history data is extremely important in determining if the patient is living in unfit conditions, has cardiac abnormalities, struggles with mobility, has underlying musculoskeletal injuries or deformities, has challenges with medication compliance, or battles with nutritional deficiencies and appetite barriers. Also, asking questions specific to the medications the patient takes is extremely important data that could help clue in the APRN as to what medications could be leading to the falls or what medications need to be titrated to ensure the patient is not put at further risk for falls NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY.
Hamrick, I., Norton, D., Birstler, J., Chen, G., Cruz, L., & Hanrahan, L. (2020). Association Between
Dehydration and Falls. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 4(3), 259–265.
Tyndall, A., Bailey, R., & Elliott, R. (2020). Pragmatic development of an evidence-based intensive care unit
specific falls risk assessment tool: The Tyndall Bailey Falls Risk Assessment Tool. Australian Critical
Care, 33(1), 65–70. https://doi.org/10.1016/j.aucc.2019.02.003 NURS-6512N Week 1: Discussion BUILDING A HEALTH HISTORY