NURS 6512 BUILDING A HEALTH HISTORY K.Vail Initial post: 16 year old white female who lives in the inner city

           The basis of assessing the health history is similar between age groups. However, there can be variations related to age and developmental understanding. This particular scenario relates to a 16-year-old white female living in the inner city. The patient is in an age range that automatically places her at increased risk for injury due to their inherent risk-taking behaviors (Jane W. Ball, 2019).  

According to the Journal of American Medical Association, “eight million persons age 12 years or greater met diagnostic criteria for drug abuse or dependence (US Preventive Services Task Force, 2020)”, and in 2017 seventy thousand fatal overdoses occurred (US Preventive Services Task Force, 2020). When evaluating and communicating with an adolescent, ensure privacy and confidentiality. The pre-visit questionnaire is named in the literature as it helps adolescents communicate more efficiently and effectively (Jane W. Ball, 2019).  

JAMA states that there is little to no evidence that states that risk behaviors can be effectively evaluated through adolescents’ screening tools (US Preventive Services Task Force, 2020). However, it is stated that they do not harm the patient to be utilized (US Preventive Services Task Force, 2020). One screening tool that is commonly used is the CRAFFT screening tool. This tool is used to evaluate alcohol use in adolescents. CRAFFT stands for car, relax, alone, forget, friends, and trouble (US Preventive Services Task Force, 2020). An alternative assessment tool that may help evaluate this patient may be the Health-Related Quality of Life assessment tool. Health-Related Quality of Life assessment is also known as the HRQOL. The HRQUL tool is used to evaluate physical and social functioning, mental health, and well-being. Studies suggest that the HRQOL tool may show favorable patient outcomes when adolescents have healthy lifestyles (Xiu Yun Wu, 2017). During a health history assessment, it is also recommended to address safety at home and in relationships with patients of all ages, especially those in high-risk groups. High risk for abuse groups would include minorities, children, the elderly, sick, and females (Jane W. Ball, 2019).  

The health history assessment will also assist in determining if the patient has a chronic medical condition. Combining the patient being chronically ill and this particular age group drastically increases the child’s risk for risky behaviors (Derrick Ssewanyana, 2017). Specific behaviors to monitor for would be the use of alcohol, tobacco, drugs, and inactivity (Derrick Ssewanyana, 2017). This is important because patients who are chronically ill and partake in high-risk behaviors risk treatment regimens being disrupted, leading to suboptimal results (Derrick Ssewanyana, 2017). 

           Target questions to be asked during the health history could be, “what brings you here today?” or “how are you feeling today?”. These two questions would address why the patient is here and initiate the conversation of the primary complaint. The patient could be evaluated with the CRAFFT assessment by oral or written formats. The questions would be similar to this: 

Part A would ask the patient if they drink alcohol, use marijuana, synthetic marijuana, and THC oil, and do they use anything else to get high (John R. Knight, 2016) 

1.  ”have you ridden in a car driven by someone or have you driven a vehicle high or while using drugs or alcohol?”  

         2. “Do you use alcohol or drugs to relax or feel better about yourself. Have you ever tried drugs to help you fit in?” 

           3. “Do you use alcohol or drugs while you are alone?” 

    drinking “Do you ever forget things that you did while using drugs or alcohol?” 

          5. “have your family or friends ever told you that you should cut down on your drinking of alcohol or use of drugs?” 

          6. “Have you ever gotten into trouble while you were using alcohol or drugs?” 

These questions, when asked, will be allotted a single point. If the patient scores a two or better, there is potential for a significant problem, and further evaluation is required (John R. Knight, 2016). 

In conclusion, when speaking with adolescents, consent needs to be addressed with the person who is legally responsible for them before evaluation can begin. Specific care must be taken when speaking to this 16-year-old girl to ensure privacy and confidentiality. Adolescents are at the highest risk for injury related to high-risk behaviors that they have. That is why screening tools may be helpful to evaluate patient needs during the health history assessment. Screening tools d