XH 3003 Assignment Health History Across the Lifespan

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XH 3003 Assignment

Health History Across the Lifespan

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Student Name

Walden University

XH3003: Health History Across the Lifespan

Competency Assessment: When Taking a Health History Is a Challenge

Professor Name

Date

Scenario 1: Health History for a Young Child

Archie, age 7, and his father, Gabriel Moore

Challenges in Gathering a Health History for a Young Child

The first clinic visit is conducted when the child is 7 years old, as Archie is not feeling well. This is because the nurse may encounter some difficulties in getting answers from Archie, as he may feel ill or upset to respond. The challenge that the nurse is most likely to encounter when interacting with this child is that he is new to clinic visits. Health information that the nurse has to obtain from Gabriel’s father presents some challenges in the process (Jarvis, 2023). It can also be seen that there are moments when Gabriel fails to concentrate, but it can be associated with the fact that he is worried about Archie’s health condition and, probably, does not have full access to his records. In these conditions, the nurse must gather all necessary facts and check them.

Communication Skills Needed by the Nurse

Nurse or anyone talking must use simple English to ensure that Archie and Gabriel can understand the questions asked. Archie has to be instructed to point at the site of the injury, and the nurse has to follow the direction of the pointing. A nurse should simplify his or her words and not bring in so many medical terms. In this case, the nurse should employ emotional intelligence as well as empathy (Perry & Hockenberry, 2022). The nurse should comfort Archie and show him that they understand that he is in pain, by saying things such as “I see that you are sick and we will make you well.” From the conversation with Gabriel, the nurse must focus on him and ensure that he is comfortable and willing to proceed with the interview in a quiet environment. In this case, a friendly and soft tone helps in making Archie relax as well as engaging him in small decisions regarding temperature checks.

Goals in Obtaining a Health History

We aim to obtain thorough records of Archie’s health condition, focusing on the symptoms and their progression from the onset. I need to obtain basic details of Archie’s medical history, such as his allergies, medications he is currently taking, and any pre-existing conditions he may have. When it comes to Archie and Gabriel, we want to establish trust in the task at hand. Thus, the support offered to patients will help them provide truthful information necessary to develop their treatment program.

Priority Information to Obtain

I need to know the symptoms that Archie currently has, as well as the duration of these symptoms. I need to find out whether Archie has developed any diseases lately or changed his diet, or changed any of his activities (Perry & Hockenberry, 2022). The nurse should note down Archie’s current health status and the past sicknesses that he has contracted, as well as the allergies that he has. We have to know his previous immunization record and his family’s medical history to determine what might be wrong with his health condition.

Next Steps for Making a Health Assessment

The nurse will have to assess Archie physically to evaluate his physical health and signs. The way Archie goes about it and how he reacts towards the physical checks help one understand what is causing his symptoms (Jarvis, 2023). In cases where Archie is uncomfortable or unwilling to cooperate with the nurse, then the nurse should engage him in other activities he likes or consider stepping aside for a few minutes to assist him to calm down. The nurse has to explain all the significant points to Gabriel and suggest further actions, such as further tests and therapies. The nurse should also document all findings and explain the care plan to Gabriel in a friendly manner to enable him/her to know what to do next.

Scenario 2: Health History for an Adolescent 

Jasmine Walker, age 14

Challenges in Gathering a Health History for an Adolescent

In the high school clinic, Jasmine Walker attends her sports physical without her mother. Naturally, the first time Jasmine tries to answer questions on her own, she feels insecure. Due to this, adolescents feel sensitive about the issues they are willing to discuss in group forums, and they rarely disclose personal issues such as mental health issues or substance use. Since she had always consulted her mother regarding health matters, Jasmine had to discuss her health with her (Qureshi et al., 2023). The nurse should encourage Jasmine to speak about her feelings towards the medical care without her mother’s influence.

Communication Skills Needed by the Nurse

The nurse should be frank and empathetic while talking to Jasmine so that she does not feel uncomfortable from the conversation. Active listening is key. The nurse has to say: “I will support you for all that you need.” Please do not hurry while answering any questions I may have for you. The nurse must teach about medical matters at the patient’s level and avoid using complex medical terms that the patient will not understand. The first requirement is that a nurse should have good emotional intelligence to be able to handle her or his own emotions as well as those of the patient. The nasty things that have been said to Jasmine must be identified, and how they would make her feel should be known to the nurse (M. Barch, 2021). The nurse should assure Jasmine that it is alright not to have a full understanding because she will be solving it with them. The nurse should gain the trust of Jasmine by reassuring her that whatever she is being asked will not be disclosed. Thus, the nurse can encourage Jasmine to open up by informing her that everything said will be kept in confidence, except in the case of patient endangerment.

Goals in Obtaining a Health History

As a result, our main goal is to assist Jasmine in expressing herself regarding her health issues without her mother’s intervention. The nurse should know the physical and mental state of the patient, social life, and the current events regarding health. I desire to contribute to the achievement of self-responsibility in the management of her health (Qureshi et al., 2023). I should explain to her how it is helpful to give truthful information and participate in her health care plan.

Priority Information to Obtain

First, the nurse will need to obtain some information about Jasmine’s current and past health concerns and then verify her vaccinations for a school physical examination. I need to assess how active she is and what she consumes in terms of food to confirm that she is growing as she should. During this period, young people undergo several transitions that create stress and tension, and hence, testing for emotional wellness is a priority. In performing a health assessment, you must ask her questions on social life, academics, and drug and substance abuse, among others.

Next Steps for Making a Health Assessment

The case requires that the nurse has to examine Jasmine thoroughly to determine her health status and whether she meets the school’s physical requirements. The nurse should be able to observe through the non-verbal clues of Jasmine, particularly when performing the physical examination, to avoid signs of distress. Therefore, to complete the missing details, the nurse should use more questions using a relaxed and natural conversation. The nurse then proceeds to inquire, “Is there anything else that you would like to talk about at the moment?” to allow Jasmine to speak her mind during the shooting process (M. Barch, 2021). The nurse should ensure that she informs Jasmine of the correct health information suitable for her age to ensure that she takes better responsibility for her health. I will make sure she has a healthy diet and exercise regimen, also provide her with psychological assistance, and teach her how to ask for it if required.

Scenario 3: Health History for an Older Adult 

Colleen Hart, age 76

Challenges in Gathering a Health History for an Older Adult

It is always challenging for me to convince Colleen to allow her stepson to attend our meeting. The last aspect of power dynamics she shows is insecurity about disclosing her health data when he is present. In dealing with this particular situation, the nurse has to respect Colleen’s rights to privacy and obtain the correct information on her health. Colleen should be granted full power to attend the meeting by the nurse (Sharkiya, 2023). She may have this fear because she is voluntarily giving up her part of decision-making concerning her treatment. She has memory issues and other health issues, and she finds it embarrassing to detail out her health history.

Communication Skills Needed by the Nurse

When explaining the findings to the nurse, Colleen anxiously asked about her stepson, and therefore, the nurse should use both verbal and non-verbal communication when talking to her. The second intervention is to acknowledge Colleen’s right to privacy while stating that the nurse should inform Colleen that “I understand that you would like to have a private talk and I would like to assure that you feel comfortable during this consultation.” This is evidenced by the fact that the nurse demonstrates she cares for Colleen’s best interest as a patient above all else (Zhao et al., 2022). This requires you to listen properly and to use both your body language and open-ended questions that are open to capture the patient’s trust. In this case, the nurse has to be emotionally intelligent and include the stepson while respecting the autonomy that Colleen has over her decision. The nurse should involve the stepson only when necessary and ensure to explain to Colleen the importance of his input.

Goals in Obtaining a Health History

The primary goal of care is to gather as much information as possible regarding Colleen’s health condition and respect her choice as an adult. I have to know her medical history, past health history, and her daily routine (Sharkiya, 2023). The aim is to help Colleen state her concerns and become a part of the process of healthcare decision-making while creating a safe environment. It is our goal to include the stepson in the decision-making while ensuring that Colleen’s rights to privacy are respected. I have to be on good terms with every person to establish a good working rapport with them.

Priority Information to Obtain

The information required for Colleen is her symptoms, any chronic health issues, the medications she is presently on, and any changes in her health status. It is important to screen her psychological state because many elderly patients suffer from anxiety and depression, as they do not accept help to manage their needs. To determine the general health of Colleen, I need to know what the routine of her day is, what she eats, how she sleeps, and how she mobilizes her body (Zhao et al., 2022). It may be necessary to make sure whether she can manage herself at home and whether she experiences such problems as falls or difficulties with housekeeping.

Priority Information to Obtain from the Stepson

The nurse has to elicit some crucial information from the stepson during the appointment since Colleen may not remember or want to discuss such issues. We also require information about how she administers her medicines and any changes seen in her behaviour, and how she manages her daily activities. It is important to find out how the stepson perceives her home care situation and what hazards he considers existent. That is why the nurse should maintain a professional demeanor and focus on Colleen’s needs. It is important to find a time to sit down and tell her that it is necessary to speak with the stepson to prevent quarrels and to earn her trust.

Next Steps for Making a Health Assessment

While assessing Colleen, the nurse has physical examination to conduct and at the same time, assess how well the patient is mentally. First of all, the nurse has to address various health issues and keep records of each finding made. The nurse must respect Colleen’s privacy choices by informing her the other ways of getting the information during the private session or the next appointment. Thus, it is crucial to develop a care plan with Colleen and ensure that she is a valuable employee who is appreciated.

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References for XH 3003 Assignment Health History Across the Lifespan

Jarvis, C. (2023). Physical Examination and Health Assessment – Canadian E-Book. Google Books. https://books.google.com.pk/books?hl=en&lr=&id=IWy1EAAAQBAJ&oi=fnd&pg=PP1&dq=Challenges+in+Gathering+a+Health+History+for+a+Young+Child+in+nursing&ots=7FV_7lu4f2&sig=ianRgDfC2sxc-w0mO89W6N5SM2Y&redir_esc=y#v=onepage&q&f=false

Barch , D. (2021). Developmental Cognitive Neuroscience, 52, 101031. https://doi.org/10.1016/j.dcn.2021.101031

Perry, S., & Hockenberry, M. (2022). Maternal Child Nursing Care – E-Book. Google Books. https://books.google.com.pk/books?hl=en&lr=&id=MmdjEAAAQBAJ&oi=fnd&pg=PP1&dq=Health+History+for+a+Young+Child+in+nursing&ots=SRczFeYtqU&sig=elS6ZELFHEi-sapagnB3Vb7BvA0&redir_esc=y#v=onepage&q=Health%20History%20for%20a%20Young%20Child%20in%20nursing&f=false

Qureshi, F., Guimond, A., Tsao, E., Delaney, S., Boehm, J. K., & Kubzansky, L. D. (2023). Adolescent psychological assets and cardiometabolic health maintenance in adulthood: implications for health equity. Journal of the American Heart Association, 12(2). https://doi.org/10.1161/jaha.122.026173

Sharkiya, S. H. (2023). BMC Health Services Research, 23(1), 1–14. BMC. https://doi.org/10.1186/s12913-023-09869-8

Zhao, Y. C., Zhao, M., & Song, S. (2022). ProQuest, 24(2), e34790. https://doi.org/10.2196/34790