Introduction
“A guide to taking a patient history” is an article appeared in volume 22, issue 13 of the Nursing Standard Journal in December 2007 written by H. LLoyd and S. Craig. The article talks about the steps and strategies to follow when taking a patient history. It is important to acquire good techniques in assessing a patient starting by the environment, communication skills, and a systematic approach. One must be able to collect accurate data in order to facilitate the procedure.
Summary
The article starts by emphasizing on the environment when taking a patient history. The environment should be safe for both patient and nurse. The environment should be quiet and ideally, there should be no interruptions (LLoyd & Craig, 2007). For proper gathering of the patient’s history, the environment should be prepared well in advance.
One important issue identified in the article, is communication as a foundation in managing the process of history taking. In order for adequate communication to happen between the patient and the nurse, there must be sufficient interaction between the two. Both verbal and nonverbal skills are needed. Questions should not be judgmental. Open questions give more general information about the patient. Calgary Cambridge framework is one of the method that one utilizes. The nurse should treat the patient with respect and dignity and to do everything possible to retain confidentiality.
Moreover the patient needs time to provide a complete history. It is best to avoid technical terms that the patient may not be able to understand. It is important for the nurse to express herself clearly to avoid confusion. Before starting the process, patient consent is required. It is also important to ask the patient about health beliefs and practices.
Once the general structure of history is established, one can begin asking about presenting complaint, past medical history, mental health followed by medications history. It is important to find out about over the counter medications and herbal remedies that the patient is currently taking. Family history is also a good tool in taking patient history. The patient social history should also be included along sexual history and occupational activities. The nurse needs to gather information about the other systems in the body that are not covered during the beginning of the assessment. This will reduce the chance to omit any important information.
Evaluation of the article
LLoyd & Craig (2007) have identified features that are crucial in taking patient history for instance: suitable environment, efficient communication and procedures that are engaged in the history taking process.
In this paper I will write about my observation of the Miss Z who was a 28 year old patient in the S hospital where I had my Lifespan 1 clinical placement. Also, I will write about Mrs. M. who is a Registered Nurse at the High Risk Pregnancy Unit of the S. hospital where Miss Z. was a patient. More specifically, I will describe how Non-Stress Test was done by the nurse Z. During this test nurse repositioned Miss Z, strapped two sensors to her belly, and interacted with Miss. Z. In the second part of my writing I will discuss two types of nursing knowledge such as Case knowledge and Patient knowledge. (Joan Liashenko, Anastasia Fisher 1999) I will describe how nurse Z incorporated these types of nursing knowledge into her encounter with Miss. Z.
3. When should the patient be notified of the purging of archaic or inaccurate information?
The purpose of the paper is to discuss the activities involved during the evaluation of a patient. Evaluation of a patient can be seen as the process of examining a patient critically. It comprises of gathering and analyzing data about a patient and the illness (Allan, 2012). The core reason is to make judgment about the disease one is suffering from. Such judgment will guarantee proper treatment and diagnosis. Typically, gathering of information from the patient is the role of nurses while making judgment and prescription is the doctor’s role (Jacques, 1988). In any case all practitioners are required to know how to evaluate a patient.
This is an analysis of a taped interview between a nurse and a patient who is taking pre-employment medicals. The information given during the interview, including her name, Pink Cloud is fictitious because of the need of confidentiality. During the interview, objective and subjective data will be collected. The areas of communication focused on in the analysis are verbal, questioning and listening skills. Analysis will be made and later suggestions and recommendations will be made on how to make improvements in the future. To achieve this, direct quotations from the will be used to make references to the three theories being analysed and will be supported by the literature.
Billiann replied, “An average day is started by getting a report from the previous nurse on the health status of the patient, any new orders that need to be completed, and overall health care plan. I then assess each patient and give medications as needed. If there are any new health concerns during the assessment or throughout the day I notify the physician. I always have my stethoscope, pulse ox, normal saline flushes, tape and scissors on me. Most needed equipment is already in the patient’s room.”
As health care providers, nurses strive to instill confidence in their patients and their loved ones. A nurse is respectful to their colleagues as well as their patients. Nurses promote patients’ independence, patients can be confident in the knowledge that a nurse will do what is best for them, respecting their privacy and dignity. This means that a nurse does not share the patient information for personal reasons nor does the nurse get involved in a patients personal relationship if it is not medically relevant (NCSBN, 2011).
All these steps are extremely necessary in order to get positive outcomes of the specific treatment. In the case of interrupted communication between the patients and the nurses the diversion of attention is very likely to occur. This can lead to the tendency to ignore the minute details provided by the patients which would otherwise be worth important for the course of diagnosis. Therefore, the appropriate instructions should be provided to the nurses in order to remain active and attentive towards the patients. The issues of non-compliance can also be minimised by the rational and pragmatic approach adopted by the nurses (Montes & Augusto,
Confidentiality in health care is a growing concern as nurses are often faced with the challenges of reacting to question regarding patient’s progress (McGowan, 2012). Confidentiality as defined by Gregory, Raymond-Seniuk, Patrick and Stephen (2015) is the promise given to a person that his or her personal information will not be disclosed randomly if no consent has been given regardless of who is seeking such information (p.600). This paper will attempt to explore the concept of confidentiality as a sensitive issue, challenges that nurses face as they try to protect patient’s health information and some guidelines that govern protection of information and when this information can be divulged.
As a result, I always felt that I am actively participating in patients’ care. She allowed me to perform patient examinations most of the time and encouraged me to build up a good rapport with the patients. I think my past experience and medical knowledge was helped me lot during the history taking because I was able to go through history taking in a systematic manner and at the same time I could think of possible differential diagnosis. Furthermore, working in a medical clinic as a physician assistant also helped me a lot because one of the responsibilities delegated to me is taking patients history, however, this time it was different that I had to work out and actively think about a possible cause for patient concerns. The weakness I observe during history taking was sometimes I am little quick that might hurt the doctor-patient relationship, So, I am planning to improve my listening skill with less interruption to patients, I believe that might help the patient to express their concerns freely. Also, I am determined to listen to patients concerns in a non- judgemental manner to get the unbiased clinical
Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
I introduced myself to the patient stating that I was a student nurse and gained verbal consent to carry on with the assessment, as a student nurse you must respect patients wishes at all times, if t...
The following essay is a reflective paper on an event that I encountered as a student nurse during my first clinical placement in my first year of study. The event took place in a long term facility. This reflection is about the patient whom I will call Mrs. D. to protect her confidentiality. Throughout this essay I will be using LEARN model of reflection. I have decided to reflect on the event described in this essay since I believe that it highlights the need for nurses to have effective vital signs ‘assessment skills especially when treating older patients with complex medical diagnoses.
In theory and practice, the focus of nurses is on the response of the individual and the family to actual or potential health problems. To evaluate patient care steps has to be taking that incorporates the collection of data and processing that data through critical thinking. The nursing process is essential because it incorporates this concept into a well throughout steps ...
“The history-taking interview should be of high quality and must be accurately recorded” (Craig & Lloyd, p.48). It is important that while obtaining a thorough health history, that the patient is treated with dignity and that their privacy is respected. A complete history involves the collection of physical and psychosocial aspects of one’s health.
A detailed patient history including history of any recent trauma or systemic disease such as renal or cardiovascular problems should be taken. The diagnosis is usually reached by a high clinical suspicion through the history and physical examination.