The Importance Of Building A Health History

The Importance Of Building A Health History

The discussion highlights the importance of comprehensive data collection and effective communication in treating a 19-year-old black male athlete experiencing muscle pain. The discussion acknowledges the significance of establishing a rapport with the patient, particularly in the case of adolescents and young adults. According to Molina and Gallo (2020)The Importance Of Building A Health History, creating a comfortable environment encourages patients to openly express their experiences and provide valuable subjective and objective information.

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The discussion also emphasizes using adaptive questioning and active listening as effective techniques to allow patients to communicate their concerns without interruption. I would apply effective communication and interview techniques to establish a rapport and gather comprehensive information. I would introduce myself, explain the purpose of the interview, and ensure the patient’s privacy and confidentiality. I would use open-ended questions to encourage patients to provide detailed responses and share their concerns regarding muscle pain.

Active listening skills would be essential to demonstrate empathy and understanding and encourage patients to express themselves fully. Byrne et al. (2020) assert that a patient-centered approach creates a comfortable and non-judgmental environment, allowing the patient to freely express their symptoms, concerns, and any relevant contextual information. I would use non-verbal cues such as maintaining eye contact, nodding, and appropriate body language to convey attentiveness and interest. The Importance Of Building A Health History

Assessment Tool

The OPQRST mnemonic would be the most suitable assessment tool to assess the patient’s health risks related to muscle pain. This tool explores various aspects of the pain experience, including the onset, palliative and provocative factors, quality, region and radiation, severity, and timing of the pain (Ford, 2019).

O – Onset: Determine when the pain started and what was happening then. Understanding the circumstances surrounding the onset of pain can provide insight into potential causes or triggers.

P – Palliative and Provocative factors: Identity what makes the pain better or worse. Inquire about specific activities, positions, or treatments that alleviate or aggravate the pain. This information can help identify contributing factors.

Q – Quality: Describe the pain. Is it burning, sharp, shooting, aching, throbbing, or another sensation? Understanding the characteristics and nature of the pain can assist in narrowing down potential causes and guide further assessment.

R – Region and Radiation: Determine the precise location of the pain and whether it spreads to other areas. Identifying the specific region and associated radiation can help identify potential underlying structures or systems affected.

S – Severity: Assess the pain intensity using a scale such as the functional pain scale or numeric rating scale (NRS). This will help determine how severe the pain is and how it impacts the patient’s ability to engage in daily activities. The Importance Of Building A Health History

Additionally, the functional pain scale and numeric rating scale (NRS) can be implemented to evaluate pain intensity on a scale of zero to ten and determine its impact on daily activities (Ford, 2019). These assessment tools facilitate a comprehensive understanding of the patient’s pain experience and functional limitations.

Factors Impacting the Health and Risk Assessment

Factors impacting this patient’s health and risk assessment are multifaceted and include the patient’s athletic status, ethnicity, environmental factors, age, gender, and the availability of healthcare resources. As an athlete on a scholarship, the patient may face an increased risk of sports-related injuries or overuse injuries, which could be contributing to the muscle pain he is experiencing. Furthermore, being a black male, the patient may be more susceptible to specific health conditions prevalent within their ethnic group, such as hypertension, which can contribute to muscle pain.

Environmental factors play a significant role in health risks as well. Exposure to extreme temperatures or inadequate training facilities can increase the risk of muscle pain or injury (Leyk, 2019). Additionally, the patient’s age is an essential factor to consider. As a 19-year-old, he may be more prone to musculoskeletal injuries or strains related to physical activities that are common in young adults. Gender can also impact health risks, with males potentially being at a higher risk for certain sports-related injuries or musculoskeletal conditions.

Finally, the patient’s access to healthcare, socioeconomic status, and community resources are crucial determinants of their health risks. According to the National Academies of Sciences (2019), limited access to healthcare or inadequate resources in their environment may hinder their ability to seek appropriate care for their muscle pain or address any underlying health conditions. Thus, a comprehensive data collection process is essential to assess all these factors and determine the best course of action for treating the patient effectively. The Importance Of Building A Health History

The Five Targeted Questions to Ask the Patient

  1. Can you describe the nature and location of your muscle pain?
  2. When did you first notice the muscle pain? Was there any specific event or activity associated with its onset?
  3. Have you experienced similar muscle pain in the past? If so, how did you manage or treat it?
  4. Are there any activities or movements that worsen or alleviate the muscle pain?
  5. Do you have any known medical conditions or a family history of musculoskeletal problems? The Importance Of Building A Health History

References

Byrne, A.-L., Baldwin, A., & Harvey, C. (2020). Whose center is it anyway? Defining person-centered care in nursing: An integrative review. PLOS ONE, 15(3). https://doi.org/10.1371/journal.pone.0229923

Ford, C. (2019, April 11). British Journal of Nursing – adult pain assessment and Management. British Journal of Nursing. https://www.britishjournalofnursing.com/content/clinical/adult-pain-assessment-and-management/

Leyk, D. (2019). Health risks and interventions in exertional heat stress. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2019.0537

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Molina, J., & Gallo, J. (2020). Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International Journal of Environmental Research and Public Health, 17(3), 835. https://doi.org/10.3390/ijerph17030835

National Academies of Sciences. (2019). Factors that affect healthcare utilization. In www.ncbi.nlm.nih.gov. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK500097/ The Importance Of Building A Health History