Risk Assessment instrument – Functional Assessment and Physical Disabilities NURS 6512 BUILDING A HEALTH HISTORY History of 76-year-old black male with disabilities living in an urban setting.  

NURS 6512 BUILDING A HEALTH HISTORY

History of 76-year-old black male with disabilities living in an urban setting.  

The first task during this patient encounter is to obtain a comprehensive history and physical examination (if possible). This can be prolonged due to the fact that the patient is elderly and is with disabilities.  Obtaining a comprehensive history from this patient is very important because according to Ghosh & Karunaratne (2015), “early comprehensive geriatric assessment (CGA) with good history-taking is essential in assessing the older adult”. Therefore, the first task is to employ appropriate method to obtain detailed history and physical examination of this patient.  

Description of communication and interview techniques 

            Obtaining a comprehensive medical history of elderly with disabilities can be very challenging especially if additional documentation and third parties need to be involved. Therefore I will employ patient-centered interview technique during the patient encounter to obtain necessary information from this elderly patient. Just like any other patient encounter, the first step is to make a very good impression on the patient by showing courtesy and professionalism throughout the encounter. I will show courtesy by knocking at the door before entering the room while I dress professionally with correct grooming and hygiene. I will then proceed to greet the patient and any other significant others in the room (if any), introduce myself properly with my (last name and title), and then establish patient’s preferred title and clarified my role. Depending on the situation, I will allow the patient time to be dressed and comfortably settled before and after the history with assurance of confidentially. I will ensure that the patient is comfortable throughout the encounter and remind him regularly to notify me if he feels any discomfort at any time during the history taken.  

Once the patient is comfortable enough to answer my question, I will proceed to ask for the patient name and how he would like to be addressed. Some of the questions that I will asked the patient include but not limited to the following: 

How he is feeling today?, what he think is causing your symptoms and what is his understanding of his disabilities/diagnosis? How does he feel about his illness and the treatment? How is he coping with his disabilities and the level of help he is receiving? I will also asked him if he has prepare any advance directives and who can be contacted for more information or support about his illness or hospitalization? Family members?, Friends?, Employer? Religious advisor? Attorney? I will also ask about his financial situation and how is paying for his medical care? Insurance coverage or Medicaid? Tests or treatment he may not be able to afford? Timing of payments required from him? 

Throughout the encounter, I will try to maintain eye contact and use of open ended question while discussing with the patient. Finally, I will request a confirmation from the patient that he understood me clearly and ask him to ask any question that may be bothering him about his health or disabilities. 

Risk Assessment instrument – Functional Assessment and Physical Disabilities 

In order to assess the extent of disability of the patient, I will ask direct question on how patient handle fundamental skills such that constitute Activities of daily living (ADLs. Such activities include the  following areas: grooming/personal hygiene, dressing, toileting/continence, transferring/ambulating, and eating. Patient’s response to question of (ADLs) will guide on how to help the patient to cope with his present disabilities. According to Mlinac and Feng (2016), ADLs skills are usually mastered early in life and are relatively more preserved in light of declined cognitive functioning when compared to higher level tasks. 

Finally, the extent of physical disability of the patient will be assessed. This will include the extent of mobility that can be tolerated without unbearable discomfort. This will include walking distance and range of motion in all limbs. This is very important in evaluating the patient’s independence and autonomy. It will also show the extent of his reliance on other people or assistive devices. Based on patient’s responses, result of the test and the level of social support system that that patient currently enjoys, a comprehensive management plan can be developed for proper care of the patient.   

References 

Ghosh, D., & Karunaratne, P. (2015). The importance of good history taking: a case report. Journal of medical case reports, 9, 97.