Health History Assignment for Tina Jones Shadow

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Health History Assignment for Tina Jones Shadow Health

Health History Assignment for Tina Jones Shadow Health

Complete the History Assignment for Tina Jones before completing the discussion question. Your response to the discussion questions will be based on the findings in the Shadow Health assessments.

You must submit the assessment to receive credit for the activity. Assessments that have not been submitted cannot be verified as complete.

In the health history, Tina informed you about her acute foot pain resulting from her infected wound. After your assessment, identify four SMART goals for Tina based on the findings with two evidence-based practice nursing interventions for each. How will you know if your intervention worked? If you were to perform this exam within tight time constraints, what tasks, questions and assessments would be priorities for Tina? Include a minimum of two references to support your evidence-based plan. Support your discussion and opinions with facts, relevant examples from personal nursing practice, and at least two citations from the reading or peer-reviewed professional nursing literature. Remember to use APA 6th edition formatting for all discussion posts and reference citations.

Health History Assignment for Tina Jones

Assignment: Health History – The Art of History Taking and Putting All Together w/Information Processing – Unit 2-3

Directions:

Please refer to your Shadow Health Platform.

This Comprehensive Assessment provides the opportunity to plan and conduct a full health assessment on a patient in a single clinic visit.

After completing this Shadow Health Assessment the student should be able to:

  • Document accurately and appropriately:
  • Document subjective data using professional terminology.
  • Document objective data using professional terminology.
  • Demonstrate clinical reasoning skills:
  • Use clinical reasoning to plan the organization of a comprehensive exam.
  • Gather subjective and objective data. Have an Assessment and Plan of Care.
  • Differentiate between variations of normal and abnormal assessment findings. Including a list of differential diagnosis.
  • Select and use the appropriate tools and tests necessary for a comprehensive assessment.
  • Reflect on personal strengths, limitations, beliefs, prejudices, and values.
  • Develop strong communication skills.
  • Interview the patient to elicit subjective health information about her health history.
  • Ask relevant follow-up questions to evaluate patient condition.
  • Demonstrate empathy for patient perspectives, feelings, and sociocultural background.
  • Identify opportunities to educate the patient.

To view the Grading Rubric for this Assignment (include unit 2 Assignment), please visit the Grading Rubrics section of the Course Home.

Assignment Requirements:

Before finalizing your work, you should:

  • be sure to read the Assignment description carefully (as displayed above);
  • consult the Grading Rubric (under the Course Home) to make sure you have included everything necessary; and
  • utilize spelling and grammar check to minimize errors.

Your writing Assignment should:

  • follow the conventions of Standard American English (correct grammar, punctuation, etc.);
  • be well ordered, logical, and unified, as well as original and insightful;
  • display superior content, organization, style, and mechanics; and
  • use APA 6th Edition format as outlined in the APA Progression

Reflection: Taking a Health History

In the process of building the health history of the patient, I used both principles from science and art concepts of care. The process was similar to a job interview apart from the purpose of the information derived from answering the questions. This interviewing aimed at assessing the risks and social determinants of health so that an accurate and reliable health history could be established. Therefore, hard questions or questions deemed as sensitive or personal were necessary.   

Experiences

Developing the script for the interview required both critical and reflective thinking to incorporate goal-oriented questions while at the same time minding the outcomes of the questions on the patient. The inclusion of the ‘hard’ questions was the critical step. Translating the evidence from clinical literature to suggest personal and direct closed questions was the first step towards developing. Teenage pregnancy impacts both the teenager and parents, guardians, or the custodian economically and socially. To the teenager, the health burden of adolescent pregnancy increases due to the imbalance between the physiological demands and available physical and physiological body supply in that age group. Therefore, holistic care should take into account these factors.

In the process of developing a health history, I targeted the questions toward establishing additional risks that could worsen these imbalances in biophysical and physiological imbalances in demand and supply. I also focused the interview on establishing a ground for planning for prenatal and postnatal care interventions and evaluation. Including the emotional outcomes of the health problem for the patients was guided by the idea that during the teenage period, physiological and social outcomes can cause body image and mood outcomes. Therefore, I believe that I maximized opportunities to plan holistic care through this history-taking.

Asking the Questions

Asking the questions would require setting the patient in the right mind and mood. Difficulties with had questions are related to the patient and clinician’s perceived impacts on the self-image. Fear of breaking the trust between the clinician and the patient also complicates asking hard questions. The clinician will target hornet answers and build a reliable health risks profile. The patient can withhold honest responses to the questions due to a lack of trust that the clinical will maintain confidentiality or may judge them (Nasirian et al., 2018). Therefore, reassurance and active listening are some of the strategies that would improve the outcomes of the actual interview. 

The positioning with the patient, the body language, facial expressions, the tone of the questions, and the tone of the clinician’s responses are critical in establishing authentic and truthful responses from the patient (Ball et al., 2018). The presence of a guardian in the interview suggests they would be useful for corroborative health history, but may also limit the patient’s confidence in responding to sensitive questions. Therefore, the environment in terms of noise levels, lighting, and presence of third parties are key concepts I may consider when redoing the interview differently (Flugelman, 2021).

In sum, the development of the interview is artistic and scientific. Merging scientific and interpersonal interaction principles to achieve a reliable health history was the critical underpinning of the interview script development. To achieve different outcomes, environmental considerations would be key in influencing the authenticity and reliability of patient responses and establishing a therapeutic relationship.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2018). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Mosby.

Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505

Nasirian, M., Hosseini Hooshyar, S., Haghdoost, A. A., & Karamouzian, M. (2018). How and where do we ask sensitive questions: Self-reporting of STI-associated symptoms among the Iranian general population. International Journal of Health Policy and Management, 7(8), 738–745. https://doi.org/10.15171/ijhpm.2018.18