health assesment history

 

Instructions

Conduct a health history on a family member or friend.

Using the interviewing techniques learned in Module two, gather the following information. Use your textbook as your resource.

• Present Health
• Past Health
• Family History
• Review of Systems

Summarize all collected data in four page Word doc, and include your answers to the following questions in the summary. 

1. Was the person willing to share the information? If they were not, what did you do to encourage them?
2. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?
3. How comfortable were you taking a health history?
4. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?
5. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.

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Health assessment

Abiodun Kassim

Rasmussen University

Professor Ceaira Moore

Professor Gen-Gen Gutierrez

October 17th, 2022

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Introduction

The case is about the health history of a family member who has had a history of arthritis

from a very young age. When he was 35 years who got his first joint pain, and since then, his pain

has gotten severe, and he is suffering from joint pain in the knees, ankles, and wrist. He has a

family background with this disease. His mother and father were both patients of arthritis.

Although he is getting medical treatment, now, at the age of 60, he cannot walk comfortably, so he

is reluctant to share his condition and review the system he is living in. The interview was

conducted with the patient, and the summary is given below.

1. Willingness Of a Person to Share Information and Ways Adopted Convince

The person was not willing to share his arthritis information. He has been a patient of this

disease for about 25 years. Initially, he did take this seriously and didn’t use any proper medication.

He relied on OTC and took any medicine he thought that good for his arthritis. He was a bit

aggressive as he saw both his parents in that situation, and through medicine, he never helped in

curing. So, he didn’t take his condition severe and didn’t consult a doctor at the start of the disease.

He used to prefer Panadol, diclofenac sodium, and piroxicam. He was on self-therapy. With the

passage of time, the disease got severity, and now his condition is bad. He is unable to walk.

Because of his negligence, he spoiled his health badly. When I asked them to share his information

about arthritis, he was reluctant to share. But he is soft-hearted and has a very good friend to me. I

asked and took permission. Told him about my project and its importance in completing it. He

always appreciated my studies and hard work. Therefore, he melted and encouraged my efforts to

be part of the health field. So, when again I asked about his medical history, he agreed to provide

all key information. I only used the emotional strategy and motivated him that if he shared his

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information with me, I would surely find some solution so he could able to walk. Like I convinced

him to do joint replacement and provided examples of patients in the hospital that joint

replacement helped them walk again.

2. Was there any part of the interview that was more challenging? If so, what part and

how did you deal with it?

Common observations and research have revoked that interviewing patients suffering from

long-term disease is sometimes challenging(Hardavella, 2017). There are different cases when it’s

hard to communicate with a patient to get an appropriate answer. During my interview with my

uncle, the time was challenging when he briefed me about his self-medication and his negligence

regarding the treatment. In that case, I have inappropriate words and phrases to ask why he was so

negligent, as he had a history of arthritis in his family. He was reluctant to consult doctors and

health practitioners to take the right medicine. He was in an emotional state while describing all his

information, and I was confused about how I should ask this question. I need some proper way, as

my inappropriate style can hurt him more, or he may get aggressive in providing further

information. Instead of asking why he was negligent, I transformed my question into how he felt

that days about the symptoms of arthritis initially, so he took the disease lightly when it initiated.

My way was so polite and friendly. During that time, I also did some routine gossip so he could

provide me with the reason why he was so negligent about the disease at the start.

3. Comfort Level While Interviewing Patient

I was comfortable talking with the uncle as we have good terms, and he always enjoys our

discussion on his favorite topics. Although he showed reluctance in sharing his disease’s

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background, the reason for the initiation of the disease, his negligence, and the reason for ignoring

symptoms at the start, he shared all formation. In fact, he appreciated my efforts and narrated some

important incidence and all the information regarding his visit to the hospital, interaction with

different doctors, and treatment strategies he followed. Thus, the whole interview time was

comfortable. In fact, the cooperation of my uncle to provide information made all-time comfortable

and easy.

4. Interview Technique Used, Challenges to Deal and Ways to Overcome the

Situation

I adopted the “patient-centered” interview technique. The type of biopsychosocial model

includes the psychological, biological, and social dimensions. The technique is more about the

patient suffering from disease as compared to the health condition itself(Lappen, 2011). I used this

technique because the patient was already depressed about his condition. Because of so prolonged

illness, he is now suffering from depression also. So, dealing person with an inappropriate mental

state is a hard thing. Thus, initially, I motivated him that he could come out of the situation. I made

promises to spend time and help him get better, and I acted as a friend instead of a health

practitioner. Thus, the use of the patient-centered technique helped me to interview without any

hassle. As discussed, in the start, he was not willing to provide details about his health, but my soft

tone, friendly language, and hopeful sentences gave him the confidence to provide even minor

details.

5. The assistance of nurses with health information.

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Data gathering of the patient is of two types. One is subjective, and the other one is

objective(Doyle, 2015). I took the information in both a subjective and objective way. Initially, I

made a report for the signs and symptoms that my uncle described to me that were not noticeable,

but he felt and provided details about the pain in various body parts. I took all demographic

information, family information, and social history. I got all the health history that can help the

nurse to assess the health promotion practices and how to perform the procedure to educate the

patient. The main purpose of the medical history from the patient is to help understand the patient’s

state and help create the follow-up plan.

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References

Doyle, G. R., & McCutcheon, J. A. (2015). Clinical procedures for safer patient care. BC Open Textbook

Project.

Hardavella, G., Aamli-Gaagnat, A., Frille, A., Saad, N., Niculescu, A., & Powell, P. (2017). Top tips to deal

with challenging situations: doctor-patient interactions. Breathe, 13(2), 129-135.

Lappen, J. R. (2011). History-Taking and Interview Techniques and the Physician-Patient

Relationship. Glob libr women’s med.