Building a Health History for a 76-year-old Male Case Scenario

Building a Health History for a 76-year-old Male Case Analysis – NURS 6512 week 1 Building a Comprehensive Health History examples

The patient is a 76-year-old male that is African American. He has disabilities and is living in an urban setting. The goal is to build a complete and thorough health history and prevent any misperceptions or misinterpretations (Ball et al., 2019). This is the first encounter with the patient, and the advanced practice registered nurse (APRN) needs to begin building a relationship with the patient and telling them that you want to know about the patient to help with treatments and that you are available to answer any questions and provide explanations for them. Ask the patient how they would like you to address them. It is important to ask open-ended questions (Ball et al., 2019). Precede by asking them how they are feeling today and what their goal is with this appointment. Holistically, it is essential to ask about the physical, emotional, spiritual, cultural, and psychosocial aspects of their diseases or disorders and how they are coping.

Some cultural consideration when asking questions about diet is to not consider foods as bad or good. Some of the foods that the APRN may consider bad could be cultural food for the patient (Pruski, 2019). The APRN should establish a trusting relationship and explain that they are interested and want to know about their cultural beliefs so that together they can develop a treatment plan that meets their holistic lifestyle. Pruski (2019) explains that African Americans may be reluctant to disclose information about their personal or cultural life due to mistrust. Providing specific techniques helps the patient feel heard, comfortable, and supported while getting an adequate history. One technique when speaking with this patient, who is elderly and has disabilities focus on one question at a time, allow time for responses, and speak clearly, slowly, and at a voice level that they can hear (Ball et al., 2019).

Open-ended questions allow patients to give more information about their health, expound on their focus and expectations, and provide a sensation of being heard (Benham-Hutchins et al., 2017). Asking more detailed questions to narrow down the open responses afterward helps keep the interview focused and allows for clarification (Ball et al., 2019). The APRN should position themselves so that the elderly patient can see their face when they are speaking or asking questions (Ball et al., 2019). This patient is elderly and is disabled so speaking slow, clear, and asking if they can hear you ok or if you need to talk softer or quieter helps ensure that they can hear the questions being asked. If they are unable to hear and understand the question, the results can be skewed.

The APRN should focus on the patient while asking questions and not looking through notes, computers, or writing information gives the patient a sense that the APRN is attentive to what they are saying. Allowing time for responses also provides this sensation of having time for them. Together these techniques begin to establish a trusting patient-provider relationship. During a final review with the patient, explain to the patient that they can fill in gaps or misunderstandings that the APRN is saying. The review allows for confirmation of details and the patient to agree with the interpretation of the assessment (Ball et al., 2019).

This patient is elderly and has a disability, so a functional risk assessment is needed. This assessment is appropriate and determines if the patient is safe and that their needs are being met. The APRN should ask about mobility, activities of daily living (ADL), instrumental activities of daily living (IADL) (Ball et al., 2019). Another instrument that the APRN should use is the Geriatric Depression Scale instrument. This tool is applicable because the patient is at higher risk for depression through the aging process and having disabilities. The instrument has fifteen yes or no questions. Certain questions should be yes, and others should be no. One point is given for each answer that is correctly answered. If the patient\’s score is more than five, this points to depression (Ball et al., 2019).

The following are questions targeted directly to the patient for safety risks:

1.       Do you feel happy?

2.       Do you have a support system? How much support do they provide?

3.       Can you tell me your daily routine?

4.       What does your meal preparation and diet consist of?

5.       How do you get meal supplies?

6.       Listing each ADL, ask how these are completed (Independently/needing assistance)?

7.       Ask if they have any financial burdens or hardships? Do you complete your financials?

Questions like these allow the APRN to assess if the patient\’s ADLs and IADLS are being met by the patient or others\’ assistance. If this does not appear to be met, the APRN can seek out services for the patient.


Ball, J., Daines, J., Flynn, J., Solomon, B. & Stewart, R. (2019). Seidel\’s guide to physical examination. 9th edu. [MBS Direct]. Elsevier.

Benham-Hutchins, M., Staggers, N., Mackert, M., Johnson, A. H., & deBronkart, D. (2017). \”I want to know everything\”: a qualitative study of perspectives from patients with chronic diseases on sharing health information during hospitalization. BMC Health Services Research17(1), 529.

Pruski, T. (2019). Cultural awareness for African Americans and health. DC Health Matters.

Second Student Response to Case Scenario:

Summary of the Interview

The purpose of a patient interview is to establish or maintain a trusting professional relationship and obtain enough information about the patient to provide safe, effective, patient-centered care (Ball, Dains, Flynn, Solomon, & Steward, 2019). Interview techniques that are supportive of these goals include maintaining appropriate eye contact, body language awareness, active listening, and clarifying communications to ensure. The information obtained should include a thorough subjective patient history, which includes their chief concern, the history of their present illness, past medical history, family history, social history, and a review of systems (Ball, Dains, Flynn, Solomon, & Steward, 2019).

Communication Techniques

Communication with patients should be considerate of their needs and cultural preferences. Providing culturally competent care helps to reduce healthcare disparities, which is imperative to improving patient outcomes. Understanding, respecting, and valuing cultural differences is a vital aspect of promoting patient compliance and encouraging patients to be active participants in their care (Ball, Dains, Flynn, Solomon, & Steward, 2019). The Respect Model offers effective communication techniques that are considerate of cultural differences. This model focuses on establishing a rapport with the patient, being empathetic to their circumstances, offering support as they pursue their health goals, optimizing the patient-provider partnership through effective collaboration, providing education to improve health literacy, cultural sensitivity, and creating a trusting relationship (Ball, Dains, Flynn, Solomon, & Steward, 2019).

Risk Assessment and Targeted Questions

One risk assessment that should be performed for the 76-year-old Black male with disabilities living in an urban setting is a functional assessment. This focuses on determining how safely and effectively he is able to perform activities of daily living (Ball, Dains, Flynn, Solomon, & Steward, 2019). One question that could be asked is how much difficulty he has with mobility and moving short distances as well as longer distances. A second question that could be asked is whether his disabilities interfere with eating, whether that be grocery shopping, cooking, or the physical act of consuming food (Ball, Dains, Flynn, Solomon, & Steward, 2019).

A second risk assessment tool that should be utilized in this case is MeTree, which is a program that is completed by the patient through and online format to evaluate their risk for various types of cancer, cardiovascular diseases, and metabolic diseases based on their family health history (Wu & Orlando, 2015). According to a study performed by Deckx, et al. (2015), abnormal risk assessment scores in geriatric primary care patients without a history of cancer are indicative of a greater risk for functional decline and reduced quality of living after 1 year.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Steward, R. W. (2019). Seidel’s guide to

physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G.,

van Abbema, D. L., & Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16(1), 1-12.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family

health history: Barriers and benefits. Postgraduate Medical Journal, 91(1079), 508.

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