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Building a Health History Essay

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Updated: Jul 18th, 2021


Nurses should utilize various approaches to build a connection with each patient. As medical professionals encounter different people in their practice, it is vital for them to understand how to approach patients in regards to their gender, age, and socioeconomic factors. For example, women’s health is often linked to pregnancy concerns, and older people’s increasing fragility is another critical aspect of their lives.

The present essay discusses the health of a 16-year old white teenager who is currently pregnant. It is known that the patient lives in an inner-city neighborhood which means that she may face some financial barriers as well. One should address health risks connected to adolescence, pregnancy, and peer pressure for the patient, for which the framework of HEEADSSS can be used.

Patient’s Potential Health Risks

The patient faces many health risks that are connected to her gender, age, and pregnancy. First of all, she is an adolescent, and young people encounter many challenges. These may include increasing concerns about body changes, relationships with friends and parents, romantic and sexual needs, bullying, substance abuse, and pressure from school (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Furthermore, the patient is a female which means that these issues are followed by risks of pregnancy, menses’ complications, hormonal changes, and disorders that appear after puberty (Ball et al., 2015).

Next, the patient may live in an environment that may encourage tobacco and alcohol abuse as well as limit her access to healthcare. Finally, the patient is pregnant – this factor significantly affects women’s health, especially if they are as young as 16 (Friebert, Callaghan‐Gillespie, Papathakis, & Manary, 2018). The combination of these aspects creates significant risks for the patient that should be acknowledged.

Risk Assessment Instrument

One of the major risk assessment tools that target multiple problems of adolescent health is HEEADSSS. This tool includes questions about “home environment, education/employment, eating, activities/affect/ambition/anger, drugs, sexuality, suicide/depression, safety” (Ball et al., 2015, p. 17). This instrument may help one to collect primary information about the young patient’s health. Firstly, HEEADSSS includes all necessary data about the patient’s mental and physical health. Second, it recognizes the need to evaluate the patient’s eating habits, school activities, and family relationships (Sullivan, 2018).

These questions are necessary to understand whether the patient feels safe and is prepared to go through with the pregnancy. According to Friebert et al. (2018), young women are at increased risk of having postpartum complications and acquiring issues related to malnutrition. Moreover, Bottorff et al. (2014) find that adolescent females are more likely than adults to smoke or drink alcohol during pregnancy. HEEADSSS includes questions about the patients’ substance use which cover these risks.


  1. The first targeted question should address the patients’ acute concerns: “Do you have any problems that you would like to discuss?”
  2. The second question is about the patient’s sexual life: “Are you in a relationship” or “Do you have a partner?”
  3. Next, the patient’s pregnancy should be acknowledged: “What is the expected date of delivery? Did you notice any changes in health after becoming pregnant?”
  4. The patient’s preparedness to having a child is another important topic: “What are your plans for the future? Do you feel prepared to have a child? ”
  5. It may also be appropriate to learn more about the father of the future child: “What can you tell me about the father of the baby? What is his age/occupation? Does he know about you being pregnant?”


The life of the discussed patient is occupied by many concerns about school, body changes, peer and parent relationships, and future plans. Moreover, the patient’s pregnancy is another factor that can significantly affect the young woman’s health. Therefore, these issues should be acknowledged by the nurse in the conversations with the patient. HEEADSSS is a risk assessment tool that covers the mentioned above topics and pays attention to the patient’s mental and physical health.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Bottorff, J. L., Poole, N., Kelly, M. T., Greaves, L., Marcellus, L., & Jung, M. (2014). Tobacco and alcohol use in the context of adolescent pregnancy and postpartum: A scoping review of the literature. Health & Social Care in the Community, 22(6), 561-574.

Friebert, A., Callaghan‐Gillespie, M., Papathakis, P. C., & Manary, M. J. (2018). Adolescent pregnancy and nutrition: A subgroup analysis from the Mamachiponde study in Malawi. Annals of the New York Academy of Sciences, 1416(1), 140-146.

Sullivan, D. D. (2018). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

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