Nursing Assessment Taking the History of a Essay

Download this Essay in word format (.doc)

Note: Sample below may appear distorted but all corresponding word document files contain proper formatting

Excerpt from Essay:

Nursing Assessment

Taking the history of a patient is a crucial aspect of patient assessment and treatment. A good history can mean the difference between a successful patient outcome and unsatisfactory outcomes. However, taking a complete and useful history is a skill that is developed by means of training and practice; it is not some talent that is innate (Bickley & Szilagyi, 2007; McKenna et al., 2011). According to Craig (2007) nurses are increasingly being asked to take patient histories. Given these growing responsibilities nurses need training and guidelines to taking an adequate patient history. The following is a summary and critique of Craig, L. H, (2007), A "Guide to Taking a Patient's History" in Nursing Standard, volume 22, issue 13, pages 42-48.

Craig (2007) takes a comprehensive approach to explaining the interview and history taking process. This approach is applicable for most any patient population; however, Craig does not address certain cultural issues that could be important in gleaning an accurate and complete history, especially when discussing sexual issues, psychiatric issues, and other aspects of one's background that might spark some cultural tensions. Alarcon (2009) offers some insights in how to handle these issues and one's reactions to them. That notwithstanding, Craig offers some very useful information in regard to taking a complete patient history.

Craig (2007) begins with discussing issues that many other articles on this topic overlook or perhaps take for granted in regards to their importance on completing an accurate patient history. For instance, Craig is important to point out that the environment in which the history is taken should be safe and private to allow the patient to be at ease when giving their history. Craig emphasizes the importance of early rapport building by being genuinely concerned, introducing oneself, and explaining the reasoning behind all the upcoming questions before getting started with the actual assessment. Moreover, Craig stresses that the nurse-assessor be a good listener, allow patients or family members to relay information at their own pace, and not to be judgmental regarding the information that is given to them. Just doing these simple things will often result in patients or their relatives revealing information that they would not otherwise reveal without specific prompting (McKenna et al., 2011).

Even though Craig does outline a specific order for which to take the patient's history, he does not believe that it is necessary to adhere to a specific order. In a sense this may be true; however, adhering to a rigid order may also safeguard against forgetting to include important information or losing once place in the interview process if there is an interruption (McKenna et al., 2011). Craig also recommends starting with open-ended questions, and following these with closed questions and clarification queries, which is a sound strategy.

Actually, the most important issue should be the first question which is asked which is of course inquiring about the presenting complaint (Alarcon, 2009). Craig lists a very helpful series of questions that can be crucial in filtering out useful information regarding the presenting problem which I would suggest could be easily converted into a mini-checklist or structured format for one to follow using the open-ended, closed, and clarification sequence described earlier. Following a complete inquiry into the presenting complaint one should then proceed to the prior medical history again following the open-closed-clarification method. Often, patients will fill out forms listing previous medical conditions and this can be a useful guide and time saving device, something that Craig does not mention. In order to avoid redundancy and to save time nurses need to be able to read these forms quickly, learn what information to ask for based on the responses in these surveys and add important information as needed. Craig provides a useful list of symptoms that could be used as a symptom check-off list (Box 4, p 45) should one be employed in a clinic that does not have structured lists of symptoms and past medical issues to give to patients. There are a number of texts and papers that also provide comprehensive lists to use in ascertaining current symptoms and medical history and nurses should advocate for the use of such lists in their work environment in order to make the assessment process more efficient (McKenna et al., 2011).

Craig also stresses getting a good medication history, mental health history, family medical history, social and sexual history, and substance abuse profile and provides sufficient guidelines to obtaining relevant information for these domains. The medication history is crucial as is the family medical history and mental health, but some may not view the patient's full social history, occupational history, and sexual history as crucial in many contests. Depending on the context and presenting complaint this may be true; however, there are certain aspects of a patient's social history (e.g., is the patient married) that are crucial. In terms of the patient's occupational and even educational background it may initially be sufficient to ask a few relative questions such as is the patient employed and what kind of work do they engage in as well as their highest completed level of education. Such information may provide useful helpful hints on how to communicate with the patient, the patient's level of understanding, and the patient's support group. It may not be necessary to initially complete a full social-psychological profile of a patient. In terms of asking a patient their sexual history, this is a sticky question in many contexts, and it might be more useful ask for relevant information as part of the genitourinary assessment in the medical history. Later on if more detail concerning the patient's past social, occupational, and sexual history is needed it can be asked.

These last issues again raise the question of devising effective surveys for patients or their families to complete and then having the nurse review the completed forms and ask relevant clarification questions as opposed to having a nurse take a complete history in person. First, such a process eliminates certain obstacles that can arise during a lengthy interview such as poor rapport or miscommunication. Patients and their relatives understand the need to give such information and often readily complete them. Third, surveys and checklists take the burden off both patient and nurse with regards to answering sensitive questions as well as the prospect of someone overhearing personal information. Fourth, of course such a method saves time for both the patient and the nurse as a nurse can administer several surveys to patients and then complete them as the patients complete them. The use of such surveys should not be considered an excuse for nurses or other assessors not to know what information should be taken when getting an adequate patient history or how to ask questions and develop rapport, but should be used as a device to improve efficiency. Nurses, physicians, and other health care workers should still be trained in the methods of obtaining a patient history. There is actually some research to indicate that the use of comprehensive surveys and checklists followed by trained clarification interviews results in more accurate patient histories being taken than either one alone (Bickley & Szilagyi, 2007). The key is of course to have nurses who are trained to review the forms and ask the pertinent questions. Moreover, there may be situations where the patient is unable to complete a written survey and nurses can use the survey as a form of structured interview.

There is one other crucial element that is missing from the Craig synopsis that should be included with every history, a basic mental status assessment. Craig does not even approach this topic; however, it is crucial when asking any patient questions regarding their history to include basic mental status information. Such information can help to validate or invalidate the…[continue]

Cite This Essay:

"Nursing Assessment Taking The History Of A" (2012, January 14) Retrieved December 10, 2016, from http://www.paperdue.com/essay/nursing-assessment-taking-the-history-of-77511

"Nursing Assessment Taking The History Of A" 14 January 2012. Web.10 December. 2016. <http://www.paperdue.com/essay/nursing-assessment-taking-the-history-of-77511>

"Nursing Assessment Taking The History Of A", 14 January 2012, Accessed.10 December. 2016, http://www.paperdue.com/essay/nursing-assessment-taking-the-history-of-77511

Other Documents Pertaining To This Topic

  • Chronic Wound Care Nursing Assessment and Intervention

    Chronic Wound Care: Nursing Assessment And Intervention Chronic Wound Care: Nursing Assessment and Intervention Chronic Wound Care: Nursing Assessment and Intervention Chronic wounds are a challenge for both the clinician and the patient. For the nurse, issues of chronic wound care include the type of wound, the condition of the patient, and presence of infections, possible antibiotic therapy, and patient education on chronic wound care management. For the patient, issues revolve around how the

  • Nursing What Effect Does Simulation

    Learning in adults is most effectual when the environment is both participative and interactive. Another important characteristic is that learners obtain instantaneous feedback. Teaching methods that necessitate a learner to think though data or information and come to a conclusion or forecast an outcome are more valuable than is reading or lecture. "The minute-to-minute care and monitoring of critically ill patients requires nurses to collect, analyze, and react to

  • Nursing Organization Plan Nursing Org Plan the

    Nursing Organization Plan Nursing Org Plan The author of this report is asked to lay out a master plan for a nursing/medical organization spoken and enumerated from the standpoint of a new nursing executive. The plan given in this report will have six major sections. In the same order in which they will be covered in this report, these facets include contextual information, nursing strategic planning, culture and image, physical setting and

  • Nursing Theory Discuss Several Aspects of Professional

    Nursing Theory "Discuss several aspects of professional communication as it relates to the use of language in terms of form (e.g., clarity, accuracy) and content (culture and/or ethics)." (Question, 2014, p1). Communication is the reciprocal process where messages are received and sent between two or more individuals. Communication involves exchange of ideas, or opinion, which could be in form oral or written form. On the other hand, communication involves a series of

  • Nursing Theory Imogene King

    Nursing Theory Analysis Theory-based nursing is the phenomenon that has been researched much during the past two decades. Nursing theory has become the foundation for nursing practice with its own knowledge base. The current paper is an analysis of King's theory of goal attainment. King acquired her goal attainment theory model from an interpersonal system and a behavioral science. The nurse and patient communicate to achieve a common goal of patient

  • Nursing Theory a Patient Centered Approach

    Nursing Theory -- a Patient Centered Approach In the opinion of this author and from personal experience, nursing has to be patient centered. It is the author's experience in years of working in the field that someone who stays in the profession inevitably must see nursing as not a job, but rather as a vocation or a calling. One must treat it with a reverence. In this way, the nursing professional

  • Nursing Leader

    Nursing Sills Grayce Sills and Nursing Leadership Brief Biography: Grayce Sills dedicated her life's work to improving conditions for psychiatric health patients, both through reforms in the area of psychiatric nursing and through education of future generations of nurses. During the era succeeding World War II, the psychiatric nursing profession was making its first forays into mainstream treatment orientation. Grayce Sills would emerge into the profession during this time and, in the late


Read Full Essay
Copyright 2016 . All Rights Reserved