Week 1 Health History Discussion.

Health History

A health history is a conversation between the patient and health provider. It is

used to build and establish a relationship with the patient as well as reveal the issues and problems that need attention. The health perspective is a full report based on the patient’s perspective not the health care provider’s. It is imperative to give full attention during the time of interview to collect all data possible for best diagnosis and treatment. The patient I choose to do a health history on in this discussion is the 76 year old male with disabilities in an urban setting.

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Interview and Communication Techniques

Before entering in the room to interview my patient I would do an overview of the patient’s health information that was already obtained. “A change in knowledge, experience, cognitive abilities, and personality may occur with aging”(Ball et al., 2015). Therefore it is important anticipate any effects this may have on the interview. After entering the room, introducing myself as a student at Walden University and full name is the first thing I would say. The older patient may have sensory losses due to his age such as hearing or seeing. I would speak clearly and slowly facing the patient due to the older age and disabilities. It is important not to shout at the patient because this can magnify the problem by deforming consonants and vowels. Adapting to the patient’s disabilities is ideal. I would use the caregiver or family member and health record as resources to find out the disabilities of the patient so the interview can be conducted in the best manner possible. If using a electronic device it is important to not neglect the patient. It builds trust and makes the interview more personable when facing the patient and listening as well as possible (Ball et al., 2015).

Risk Assessment Tool

The OLDCARTS assessment tool is used to ensure a comprehensive presentation by making sure all characteristics of the problem are identified. It can be used for the 76 year old male to get a baseline of what is going on with him. The aim of the OLDCARTS assessment is listed below (Ball et al., 2015).

1. Onset of the problem

2. Location of the problem

3. Duration of the problem

4. Character of the problem

5. Aggravating/associated factors of the problem

6. Relieving factors of the problem

7. Temporal factors of the problem

8. Severity of symptom

The next assessment tool that would be good to use for the 76 year old black male with disabilities would be the geriatric assessment. The geriatric assessment tool was created to evaluate an older person’s functional ability, physical health, psychological health and socioenvironmental circumstances. It differs from a regular comprehensive assessment by focusing on functional capacity and quality of life (Elsawy 2011).

The last assessment tool that could benefit in the proper health history performed on the older patient with disabilities is the Fulmer SPICES assessment tool for older adults. Problems seen in older adult include, sleep disorders, issues with eating or feeding, incontinence, confusion, problems with falling and poor skin integrity (Meridith & Terry 2002). SPICES stands for:

S is for Sleep disorders

P is for Problems with eating or feeding

I is for Incontinence

C is for confusion

E is for evidence of falls

S is for the skin breakdown

Heath History Questions

1. What brings you in today?

2. How long has this been going on?

3. What time of day does this effect you the most?

4. What are your living situation and your daily routine?

5. How does your disabilities effect what brought you in today?

Resources

Ball, J.W., Dains, J.E., Flynn J.A., Solomon, B.S., & Stewart, R.W. (2015). Seidel’s

guide to physical examination (8th ed.) St.Louis, MO: Elsevier Mosby.

Elsawy, B., Higgins, K.E.(2011). The geriatric assessment. American Family

Physician. Vol.83 pp.48‐56.

Meredith, W., & Terry, F. (2002). Fulmer SPICES: An Overall Assessment Tool of

Older Adults. Dermatology Nursing, 2, 124.