Conducting a Health History: Insights from a Sickle Cell Patient

QUESTION

Conduct a health history on a family member or friend. You can use the form in your Health Assessment lab manual. Conduct a health history on a family member or friend. You can use the form in your Health Assessment lab manual book or from Week Two classroom assignment (the patient I wrote on is a 32-year-old male sickle cell patient who came to the hospital due to sickle cell pain/crisis). Using the interviewing techniques learned in Module 2, gather the following information.

• Present Health
• Past Medical Health
• Family History
• Review of Systems

While this is only a partial health history, summarize the information you gathered in four to five pages.

Include your answers to the following questions in the summary:

1. Was the person willing to share the information? If they were not, what did you do to encourage them?
2. Was there any part of the interview that was more challenging? If so, what part and how did you deal with it?
3. How comfortable were you taking a health history?
4. What interviewing techniques did you use? Were there any that were difficult and if so, how did you overcome the difficulty?
5. Now that you have taken a health history discuss how this information can assist the nurse in determining the health status of a client.

ANSWER

Conducting a Health History: Insights from a Sickle Cell Patient

Introduction

This essay presents a summary of the health history conducted on a 32-year-old male sickle cell patient who presented to the hospital due to a sickle cell pain crisis. The health history includes information on the patient’s present health, past medical health, family history, and review of systems. Additionally, the essay discusses the challenges faced during the interview, the use of interviewing techniques, and the significance of health history in determining a client’s health status.

Summary of Health History

Present Health

The patient reported experiencing severe pain in various parts of the body, particularly in the back and extremities. He mentioned feeling fatigued and experiencing difficulty breathing during the crisis. He has a history of recurrent sickle cell pain crises, which usually require hospitalization for pain management and supportive care. The patient is currently taking hydroxyurea to reduce the frequency of crises and folic acid supplements to support red blood cell production.

Past Medical Health

The patient has a significant medical history of sickle cell disease, diagnosed during childhood. He has undergone multiple hospital admissions for sickle cell pain crises, and his treatment mainly involves pain management, hydration, and oxygen therapy during crises. He reported experiencing frequent infections, particularly in childhood, requiring antibiotic therapy. Otherwise, he is relatively healthy, with no major surgical procedures or chronic medical conditions.

Family History

The patient’s family history is notable for sickle cell disease. His mother and one sibling also have sickle cell disease, and they have experienced similar pain crises and complications associated with the condition.

Review of Systems

The review of systems revealed occasional headaches, mild shortness of breath, and fatigue, which are common in patients with sickle cell disease during crises. No significant abnormalities were noted in other systems.

Answers to Questions

Willingness to Share Information

The patient was willing to share information about his health history. Establishing a trusting and empathetic rapport was crucial in encouraging open communication. I ensured a non-judgmental and supportive environment, assuring the patient that his information was essential for optimal care.

Challenging Part of the Interview

The most challenging part of the interview was discussing the patient’s recurrent pain crises and the impact of sickle cell disease on his life. This brought up emotional distress, and the patient became reserved. To address this, I expressed empathy and allowed him time to process his feelings before proceeding with the interview.

Comfort in Taking the Health History

As a nurse, I felt relatively comfortable taking the health history. My training in communication and interviewing techniques helped build a strong foundation for conducting a comprehensive and sensitive health assessment.

Interviewing Techniques Used

During the interview, I utilized active listening, open-ended questions, and reflective responses to foster effective communication. The use of empathy and reassurance helped establish a therapeutic relationship, enhancing the patient’s willingness to share information.

Significance of Health History in Determining Health Status

The information gathered in the health history is invaluable for determining the patient’s health status. It helps identify the impact of sickle cell disease on the patient’s daily life, any triggers or exacerbating factors, and patterns of recurrent crises. Understanding the family history of sickle cell disease provides insights into potential genetic risks and informs the development of a personalized care plan. The review of systems aids in identifying any associated complications or comorbidities, guiding the nurse in delivering holistic and patient-centered care.

Conclusion

Conducting a health history on a sickle cell patient was an essential step in understanding the individual’s unique health needs and challenges. By using effective interviewing techniques and fostering open communication, I gained valuable insights into the patient’s present health, past medical history, family history, and associated symptoms. This information plays a pivotal role in determining the health status of the client, facilitating personalized care and interventions to improve the patient’s quality of life and overall health outcomes.