NURS 6512 Week 1 Discussion: Building a Health History

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NURS 6512 Week 1 Discussion: Building a Health History

NURS 6512 Week 1 Discussion: Building a Health History

Building a Health History

Effective communication is vital to constructing an accurate and detailed . A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a for one of the following new patients:

  • 76-year-old Black/African-American male with disabilities living in an urban setting
  • Adolescent Hispanic/Latino boy living in a middle-class suburb
  • 55-year-old Asian female living in a high-density poverty housing complex
  • Pre-school aged white female living in a rural community
  • 16-year-old white pregnant teenager living in an inner-city neighborhood

To prepare for Building a :

With the information presented in Chapter 1 in mind, consider the following:

  • 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 age, gender, ethnicity, or environment?
  • What risk assessment instruments would be appropriate to use with each patient?
  • What questions would you ask each patient to assess his or her health risks?
  • Select one patient from the list above on which to focus for this Discussion.
  • 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 26 of the course 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 Building a Health History

Post a description of the interview and communication techniques you would use with your selected 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.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two 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.
  • Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following new patients:

76-year-old Black/African-American male with disabilities living in an urban setting

Adolescent Hispanic/Latino boy living in a middle-class suburb

55-year-old Asian female living in a high-density poverty housing complex

Pre-school aged white female living in a rural community

16-year-old white pregnant teenager living in an inner-city neighborhood

To prepare:

With the information presented in Chapter 1 in mind, consider the following:

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 age, gender, ethnicity, or environment?

What risk assessment instruments would be appropriate to use with each patient?

What questions would you ask each patient to assess his or her health risks?

Select one patient from the list above on which to focus for this Discussion.

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 26 of the course 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

Post a description of the interview and communication techniques you would use with your selected 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.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two 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.

NURS 6512 Week 8 discussion: Assessing Muscoskeletal Pain

The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provide the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

Case 1: Back Pain

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Note: Please view the Week 8 Discussion area to view the image for Case Study 1.

Case 2: Ankle Pain

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?

Note: Please view the Week 8 Discussion area to view the image for Case Study 2.

Case 3: Knee Pain

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

Note: Please view the Week 8 Discussion area to view the image for Case Study 3.

To prepare:

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

By Day 3

Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Include how the patient X-ray helped you to refine the differential diagnosis.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

NURS 6512 Week 9 Discussion: Assessing Neurological Symptoms

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

Case 1: Headaches

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

Case 2: Numbness and Pain

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Case 3: Drooping of Face

A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

To prepare:

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 9”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

By Day 3

Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

NURS 6512 Week 10 Discussion: Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with health care professionals issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

Case 1: Rectal Bleeding

A 62-year-old male construction worker reports to your clinic after experiencing rectal bleeding for over 1 month. He has noticed small amounts of blood after every bowel movement. He had a colonoscopy 2 years ago with normal results. The patient has no fever, chills, dysuria, abnormal urinary frequency, or abdominal pain. The patient reports occasional rectal itching and pain. He states he has no noticeable sores on his rectal area and no family history of colorectal cancer.

Case 2: Dysuria

A 55-year-old African-American male reports to your clinic complaining of frequent and painful urination for the past 2 months. The patient is sexually active and has been in a monogamous relationship for the past 3 years. He reports no penile discharge, fever, chills, abdominal pain, or back pain. His father is deceased and passed away of colon cancer. His father had a history of benign prostatic hypertrophy (BPH). The patient considers himself as a healthy male. He works for a large American corporation, has a relatively healthy diet, and exercises 4 to 5 times per week.

Case 3: Genitalia

A 21-year-old college student reports to your clinic with external bumps on her genital area. The bumps are painless and feel rough. The patient is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. The patient reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She had one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.

To prepare:

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Week 10 Discussion”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

 

By Day 3

 

Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

 

Read a selection of your colleagues’ responses.

 

By Day 6

 

Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject, and why. Identify the most likely condition, and justify your reasoning.

 

Week 11 discussion

 

Ethical Concerns

 

As an advanced practice nurse, you will run into situations where a patient’s wishes about his or her health conflict with evidence, your own experience, or a family’s wishes. This may create an ethical dilemma. What do you do when these situations occur?

 

In this Discussion, you will explore evidence-based practice guidelines and ethical considerations for specific scenarios.

 

Scenario 1:

 

The parents of a 5-year-old boy have accompanied their son for his required physical examination before starting kindergarten. His parents are opposed to him receiving any vaccines.

 

Scenario 2:

 

A 49-year-old woman with advanced stage cancer has been admitted to the emergency room with cardiac arrest. Her husband and one of her children accompanied the ambulance.

 

Scenario 3:

 

A 27-year-old man with Crohn’s disease has been admitted to the emergency room with an extreme flare-up of his condition. He explains that he has not been able to afford his medications for the last few months and is concerned about the costs he may incur for treatment.

 

Scenario 4:

 

A single mother has accompanied her two daughters, aged 15 and 13, to a women’s health clinic and has requested that the girls receive a pelvic examination and be put on birth control. The girls have consented to the exam but seem unsettled.

 

Scenario 5:

 

A 17-year-old boy has come in for a check-up after a head injury during a football game. He has indicated that he would like to be able to play in the next game, which is in 3 days.

 

Scenario 6:

 

A 12-year-old girl has come in for a routine check-up and has not yet received the HPV vaccine. Her family is very religious and believes that the vaccine would encourage premarital sexual activity.

 

Scenario 7:

 

A 57-year-old man who was diagnosed with motor neuron disease 2 years ago is experiencing a rapid decline in his condition. He prefers to be admitted to the in-patient unit at a hospice to receive end-of-life care, but his wife wants him to remain at home.

 

To prepare:

 

Select three scenarios, and reflect on the material presented throughout this course.

 

What necessary information would need to be obtained about the patient through health assessments and diagnostic tests?

 

Consider how you would respond as an advanced practice nurse. Review evidence-based practice guidelines and ethical considerations applicable to the scenarios you selected.

 

By Day 3

 

Post the explanation of the health assessment information required for a diagnosis of your selected patients (include the scenario numbers). Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations. Justify your responses.

 

Read a selection of your colleagues’ responses.

 

By Day 6

 

Respond to at least two of your colleagues on two different days who selected different scenarios than you, using one or more of the following approaches:

 

Suggest additional health assessment information that would be necessary to collect from the patient

NURS 6512 Week 1 Discussion: Building a Health History

Critique your colleague’s response, and explain alternative approaches to the situation.

 

Validate an idea with your own experience and additional research.

NURS 6512 Week 1 quiz

Question 1Drawing of stick figures is most useful to:

Question 2Mr. F. is speaking with you, the health care provider, about his respiratory problem. Mr. F. says, I ve had this cough for 3 days, and it s getting worse. You reply, Tell me more about your cough. Mr. F. states, I wish I could tell you more. That s why I m here. You tell me what s wrong! Which caregiver response would be most appropriate for enhancing communication?

Question 3During the course of the interview you should:

Question 4Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

Question 5Constitutional symptoms in the ROS refer to:

Question 6A detailed description of the symptoms related to the chief complaint is presented in the:

Question 7Which of the following is not a characteristic of the plan portion of the problem-oriented medical record?

Question 8When recording assessments during the construction of the problem-oriented medical record, the examiner should:

Question 9Mrs. G. reports an increase in her alcohol intake over the past 5 years. To screen her for problem drinking, you would use the:

Question 10During a history-taking session, Mr. B. appears to be avoiding certain questions. He keeps looking out the window. What should the caregiver do?

NURS 6512 Week 1 Discussion: Building a Health History

Question 11Mary Jane has brought in her 16-year-old son, Kyle. She states that he has been sleeping more, doesn t hang around his friends, and recently his girlfriend broke up with him. Your most immediate question is to ask Kyle:

Question 12You are collecting a history from an 11-year-old girl. Her mother is sitting next to her in the examination room. When collecting history from older children or adolescents, they should be:

Question 13J.M. has been seen in your clinic for 5 years. She presents today with signs and symptoms of acute sinusitis. The type of history that is warranted is a(n) _____ history.

Question 14A tool used to screen adolescents for alcoholism is the:

Question 15Ms. S. reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S. s loss of appetite, it would be better to:

Question 16Subjective and symptomatic data are:

Question 17Which of the following is an effective adjunct to document location of findings during recording of physical examinations?

Question 18When taking a history, you should:

Question 19Which question would be considered a leading question?

Question 20Which of the following is considered an IADL but not an ADL?

NURS 6512 Week 1 Discussion: Building a Health History

NURS_6512_Week_1_Discussion_Rubric

Excellent Good Fair Poor
Main Posting
Points Range: 45 (45%) – 50 (50%)
“Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
Points Range: 40 (40%) – 44 (44%)
“Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.
Points Range: 35 (35%) – 39 (39%)
“Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.
Points Range: 0 (0%) – 34 (34%)
“Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness
Points Range: 10 (10%) – 10 (10%)
Posts main post by Day 3.
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
Does not post main post by Day 3.
First Response
Points Range: 17 (17%) – 18 (18%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
Points Range: 15 (15%) – 16 (16%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.
Points Range: 13 (13%) – 14 (14%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
Points Range: 0 (0%) – 12 (12%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response
Points Range: 16 (16%) – 17 (17%)
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.
Points Range: 14 (14%) – 15 (15%)
“Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.
Points Range: 12 (12%) – 13 (13%)
“Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.
Points Range: 0 (0%) – 11 (11%)
“Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation
Points Range: 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
N/A
Points Range: 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on three different days.
Total Points: 100
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