Walden University NURS 3020 Health Assessment - Comprehensive Health History

Introduction

An in-depth health background interview is intended to establish a trusting relationship between the court nurse and the patient. A well-conducted interview does not simply collect essential information; it also helps build a relationship, which is the cornerstone of effective and collaborative patient-organization interaction.

The adage “first impressions are lasting impressions” holds much meaning in healthcare. A patient’s first impression when they walk into a healthcare facility for a checkup determines how they perceive care. This can contribute to how much detail and information is disclosed.

To ensure maximum exchange, nurses need to use a combination of efficient communication skills and proper interview techniques. Patient-specific factors should also be taken into account because they will determine how operative questions are formulated and how responses are understood.

For this discussion, we will consider communication and interview techniques for a 16-year-old pregnant Caucasian male living in an inner-city community. We will identify the most appropriate risk assessment tool for this patient and outline important identifying her health risks.

Risk Assessment Tool

Psychosocial information is as quintessential as a bodily evaluation at the same time as operating with more youthful humans. Huge increases and improvements mark this level of life, and numerous fitness dangers emerge due to exploration and behavioural experimentation.

For instance, sexual hobbies can also cause unintentional pregnancies or sexually transmitted infections. Moreover, young humans may also interact with substance use, developing the threat of health headaches, harm, or possibly mortality.

HEADS Assessment for Adolescents

The HEADS assessment device is our affected character’s most suitable hazard evaluation approach. This setup interview method offers a complete “psychosocial evaluation of systems” with the valuable, beneficial resource of evaluating multiple factors of a more youthful character’s life, along aspects of domestic surroundings, training and employment, eating conduct, peer-related sports, Drug use, Sexuality, Suicide/despair risk, and safety from harm and violence.

To ensure respectful and open speaking, coping with adolescent patients with the same dignity as adults is necessary. Confidentiality is critical, and whilst appropriate, the mother, father, or guardians must be requested to step out of the room to allow the affected person to speak freely (Ball, Dains, Flynn, Solomon, & Stewart, 2015).

Targeted Questions

Open-ended questions encourage young adults to share their ideas and opinions freely. Those questions allow the affected character to offer narrative responses in the desire for easy “exquisite” or “no” solutions. for instance,

• “Can you tell me approximately the pain you’re experiencing?”
• “What brought you to the health centre nowadays?”

In assessment, closed-ended questions seek specific statistics and elicit brief responses. As an example

• “Is the pain placed in your lower belly?”

Effective Communication in Healthcare

ultimately, in the interview, the healthcare provider wants to apply every verbal and non-verbal cue to inspire the affected person to preserve sharing records. Clean affirmations like “I see” or “Please cross on” can sign active listening. Silence, at the same time as it must be used, lets the affected individuals collect their ideas and enlarge their answers.

Empathy is also a necessary communication factor, as it constructs rapport and reassures the affected individual that they are being heard and understood.

To prevent miscommunication, the healthcare enterprise must respond clearly by paraphrasing what the affected man or woman has said and soliciting affirmation. This ensures accuracy and prevents misinterpretation.

Targeted Questions for Health Assessment

For this case, we advocate the subsequent targeted questions to collect in-depth fitness facts

• : “What is your property environment like? Are you able to tell me about your relationships with the circle of relatives and participants?”
• “Are you attending university or running nowadays? How do you experience approximately your critiques there?”
• “Does your weight or frame image motivate you under any pressure? are you able to describe the approach you experience approximately?”
• “How do you sense approximately your pregnancy? have you ever shared the information with your circle of relatives or accomplice?”
• “have you ever ever ever ever considered specific alternatives for your being pregnant, together with parenting, adoption, or abortion? What are your ideas?”

Conclusion

Young people often engage in exploratory behaviours without an absolute notion of capability risks. As they navigate this degree of self-discovery and private growth, healthcare professionals want to capture every interaction as a possibility to instruct and assist them in making knowledgeable alternatives. By fostering a nonjudgmental environment, companies can guide younger sufferers towards more invulnerable choices while addressing the overall spectrum of their healthcare wishes.

This method does not entirely ensure that on-the-spot health issues—including pregnancy, substance use, and intellectual fitness—are addressed; however, it creates a place where the affected character feels cosy looking for help in destiny. Conversations about sexual health, the consequences of unprotected intercourse, and the risks related to substance use should be treated with sensitivity, reinforcing the significance of informed selection-making in early life.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s Manual to Physical Exam (eighth ed.). St. Louis, MO: Elsevier Mosby.

Klein, D. A., et al. (2014). HEADS three.0: The psychosocial interview for children—updated for a contemporary century fueled via media. Contemporary-day Pediatrics. Retrieved from https://mmcp.dhmh.maryland.gov/epsdt/healthykids/archives/Sec._4_Add_p.c20HEEADSSS.pdf