NURS 6512 Week 2 Tailored History Plan Example

A Tailored Health History Plan for a Recently Widowed 74-Year-Old Man Living Alone in a Rural County

Student Name

College of Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Instructor Name

Month Day, Year

A Tailored Health History Plan for a Recently Widowed 74-Year-Old Man Living Alone in a Rural County

Patient Profile

Mr. H., invented for this plan from no single real person, is a 74-year-old retired grain elevator operator who lives alone on a farm property 38 miles from the nearest hospital. His wife of 49 years died of pancreatic cancer seven months ago after a long illness during which he was her main caregiver. He has hypertension and osteoarthritis of both knees, and he comes to the rural health clinic today because his daughter, who lives three hours away, made the appointment after noticing on the phone that he "sounds tired all the time." He describes the visit as a blood pressure check.

Three features of this profile shape the plan. He did not choose the visit, so his agenda and his daughter's differ. He carried a caregiver role for two years and has now lost both the person and the role. And he lives far from services, alone, in a community where self-reliance is valued and asking for help can feel like failure. A history that follows the standard order of chief complaint and review of systems would record his blood pressure and his knees and would probably miss the reason his daughter called.

Risk Map

The profile raises six risk domains, each tied to a specific fact. Mood is the first, because bereavement within the past year, the loss of a caregiving role, and his daughter's observation of fatigue together make depression the most pressing concern. Grief and depression overlap in the first year, and a history must separate them rather than assume either (Zisook & Shear, 2009). Alcohol use is the second domain, since older men living alone after a loss are at risk of drinking more, and alcohol interacts with his antihypertensive and his arthritis medication.

Falls are the third domain. Knee osteoarthritis, a farm property with uneven ground and outbuildings, and possible orthostatic effects from his blood pressure medication all raise the risk, and a fall with no one else at home can mean a long lie before help arrives. Nutrition is the fourth: his wife cooked, and men who lose a spouse who managed meals often eat less and less well. Isolation is the fifth, given the distance from neighbors and town. Access to care is the sixth, because a 76-mile round trip affects whether any follow-up plan is realistic.

Communication Considerations

Two features of Mr. H.'s presentation will govern how the interview is conducted. First, his stated reason for coming is narrow. Opening with the blood pressure check honors his agenda and builds the trust needed for later questions; moving directly to mood would confirm his suspicion that he was brought in to be told he is not coping. The interview therefore begins with the complaint he named and widens gradually, using transitions that explain why each new topic is being raised.

Second, grief and a reticent manner can both suppress disclosure. Older rural men often describe emotional distress in physical terms, such as poor sleep, low energy, or weight change, rather than as sadness (Ball et al., 2023). The interviewer should listen for those somatic descriptions and follow them. Silences should be allowed to run; a question about his wife may produce a long pause, and filling it too quickly signals that the topic is unwelcome. Questions about mood, drinking, and safety are asked after rapport is established, in plain language, and with a normalizing preface so that a yes does not feel like an admission of weakness.

Targeted Questions by Domain

Mood. "It has been about seven months since your wife died. How have you been getting along since then?" If he describes difficulty, the interviewer follows with "Some people find they lose interest in things they used to enjoy after a loss like yours. Has that happened to you?" and then asks directly about hopelessness and thoughts of not wanting to live. A positive answer to either leads to a safety assessment, including access to firearms, which are common on farm properties.

Alcohol. "Many people find their habits change when they are living alone. How often do you have a drink containing alcohol these days?" This is followed by the remaining AUDIT-C items on typical quantity and frequency of six or more drinks on one occasion (Bush et al., 1998). A score of 4 or more for a man prompts a fuller conversation about how drinking has changed since his wife's death.

Falls. The three screening questions from the STEADI initiative are asked verbatim: "Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling?" (Stevens & Phelan, 2013). Any yes leads to questions about where and how, whether he could get up, and how long he was down.

Nutrition. "Who does the cooking now, and what did you eat yesterday?" A concrete recall is more informative than asking whether he eats well. Weight change since the funeral is asked about specifically.

Isolation and access. "Who do you talk to in a normal week?" and "If you needed to come back here in two weeks, how would you get here?" The first identifies his contacts; the second tests whether a follow-up plan is realistic before one is made.

Selected Screening Instrument: The Geriatric Depression Scale, Short Form

The Geriatric Depression Scale was developed specifically for older adults and uses a yes or no response format that is easy to administer and understand (Yesavage et al., 1982). The original version contained 30 items, and a 15-item short form was later validated for settings where time is limited (Sheikh & Yesavage, 1986). A score of 5 or more on the short form suggests depression and warrants further evaluation, and a score of 10 or more is strongly suggestive.

Three features make it the better fit for Mr. H. than the alternatives. First, the scale deliberately omits most somatic items. In an older man with arthritis and poor sleep after bereavement, instruments that count fatigue, appetite, and sleep as depressive symptoms can overstate depression by scoring physical illness and normal grief. Second, the yes or no format suits a reticent patient who may be uncomfortable rating the intensity of feelings on a scale. Third, it was designed and normed in older populations, whereas the Patient Health Questionnaire-9, the main alternative, was validated in general adult primary care samples (Kroenke et al., 2001). The PHQ-9 remains useful for tracking severity once depression is identified, and it includes an explicit item on thoughts of self-harm that the Geriatric Depression Scale lacks, so the interviewer asks that question directly regardless of the score.

The instrument does not replace the interview. It gives a structured, repeatable measure that can be compared at follow-up, and it supports the clinician's judgment about whether Mr. H.'s low energy reflects grief, depression, or a physical cause such as anemia or hypothyroidism, which would then be pursued in the examination and laboratory plan.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist, 5(1-2), 165-173. https://doi.org/10.1300/J018v05n01_09

Stevens, J. A., & Phelan, E. A. (2013). Development of STEADI: A fall prevention resource for health care providers. Health Promotion Practice, 14(5), 706-714. https://doi.org/10.1177/1524839912463576

Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. https://doi.org/10.1016/0022-3956(82)90033-4

Zisook, S., & Shear, K. (2009). Grief and bereavement: What psychiatrists need to know. World Psychiatry, 8(2), 67-74. https://doi.org/10.1002/j.2051-5545.2009.tb00217.x