...2013 Introduction “A guide to taking a patient’s history” is an article which was written by Hiliary Lloyd and Stephen Craig, published in volume 22, issue 13, of Nursing Standard in December 2007. Lloyd and Craig describe the process of taking a health history and explain how environment and other factors affect the accuracy of the health history obtained. This article provides different methods to taking a comprehensive history and the order in which to do so. Summary of the Article Taking a patient’s health history is an integral of patient assessment and it is important that nurses hone their assessment skills while expanding their role as a nurse. Before a health assessment is taking the nurse must first have informed consent from the patient. While taking a health history it is important to choose the right environment, free from distractions if possible and safe for the patient and nurse. The nurse should convey respect for the patient as a person and maintain a level of privacy and dignity. Good communication skills are essential; the nurse must introduce herself to the patient, develop a rapport with the client by being professional, friendly and show interest by actively listening to the patient, the patient should not feel rushed or hurried. Nurses should refrain from using medical jargon when possible and utilize verbal and non-verbal communication skills. It is important to consider culture when taking a patient’s health history. Perform a cultural assessment...
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...Professor J. Deibel Spring B 2014 Journal Article Review Introduction ‘A guide to taking a patient’s history’ is an article published in the nursing standard Journal, volume 22, issue 13, dated December 5, 2007, written by Hillary Lloyd and Steven Craig. In this article, Lloyd and Craig describe the practice of obtaining a patient history in a systematic way, importance of communication skills, preparing the environment, and explaining why a thorough assessment is indispensible. Summary of Article Obtaining a patient’s history is of utmost importance, for the nurse or healthcare provider, when conducting a patient assessment. It is during this time the patient presents valuable and pertinent information. Also, it is at this time a relationship is evolved between the nurse and patient. Prior to taking the history it is important to prepare the environment. The nurse may come across many varied environments. Such as, patient’s homes, emergency room, clinics, community settings, and different areas of the hospital. Having all needed equipment accessible and area to avoid interruption is important. The environment should support safety for both the patient and nurse. Making sure enough time is allotted to conduct the assessment is stressed. “Not allowing enough time can result in incomplete information, which may adversely affect the patient’s care”(Lloyd & Craig, 2007,p.42). Communication skills need to be of high quality...
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...Taking a Patients History Introduction ‘A guide to taking a patients history’ is an article published in the Nursing Standard journal, in the December 5, 2007 volume 22, issue 13, pages 42-48, written by Hilary Lloyd and Stephen Craig. In this article, Lloyd and Craig provide an overview of taking a patient’s history related to nursing. There are certain questions that should be asked and this article outlines what to ask and how to ask it. This article also provides a great overview of cardinal symptoms for each system in the body and several methods for taking a comprehensive history. Summary Taking a successful history includes preparing the environment and effective communication skills. This is “arguably the most important part of patient assessment” (Lloyd & Craig, 2007, p. 42). In the process, patients are able to present vital information about their problem in their own words. To explore a decline in a patient’s health requires a very careful evaluation of patient needs. Allowing adequate time is essential to complete the history and avoid receiving incomplete information. The environment should be assessed first for the safety of both the patient and nurse, have no distractions, be quiet, have the right equipment and be conducted in a private setting in order to maintain patient confidentiality. Cultural consideration is important to taking the history. The assessment must be conducted with respect for the patient, an approach that requires that the patient’s...
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...outline the process of using a systematic approach on obtaining a comprehensive patient history. In order to gather the history properly, the nurse also has to use their interpersonal communication skills in an efficient and professional manner along with an assessment of the individual and their surrounding environment. Once you establish a comfortable environment for the patient, you can utilize your nursing skills to obtain a comprehensive history and present it in an orderly fashion. Summary of Article Craig and Lloyd (2007) emphasize that obtaining a patient history is “arguably the most important aspect of patient assessment” (p. 42). The nurse’s role in the health care field is every changing but utilizing the information given to them by the patient is critical in proper assessment of the problem at hand. The first step in being able to gather information from the patient is establishing an environment that is conducive to the patient and nurse interaction. The environment should be “accessible, appropriately equipped, free from distractions and safe for the patient and the nurse” (Craig, 2007, p. 42). Being considerate to the patient’s beliefs, values, and to be open minded even if the nurse does not share the views of the patient goes a long way to gain respect as well as consent from the patient. Communication skills of the nurse is also vital in attaining the patient history in that not only can the nurse properly ask the questions in a professional manner but...
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...Journal Article Review Chamberlain College of Nursing NR 305 RN Health Assessment Journal Article Review Introduction “A guide to taking a patient’s history” was written by Hilary Lloyd and Stephen Craig. The article was published in the December 5, 2007 issue of Nursing Standard. The article discusses the process of taking a patient history, preparing the environment, communication, and the importance of order. Summary of Article The patient history is an important part of the patient assessment that nurses conduct. The article provides steps on how to take a full and detailed patient history. The first step before obtaining a patient history is obtaining consent from the patient. The patient must be able to provide consent if they are able to act on their own free will and are able to understand what they have agreed to. The next step is preparing the environment. Preparing the environment includes: ensuring that the environment is safe for both the patient and the nurse, maintaining privacy, protecting patient confidentiality, and allowing enough time to complete the assessment. Communication is the next step. During this step, the nurse introduces themselves to the patient. Using active listening and allowing the patient to tell their story is very important during this step. Use of technical terms should be avoided. Questioning should begin with open-ended questions. Examples include: “Tell me about your health problems” or “How does the affect you”...
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...relationship between spirituality and medicine. There is a positive correlation between a patient’s spirituality or religious commitment and health outcomes. A spiritual assessment as a part of a health assessment is a practical step to incorporating patient’s spiritual needs into practice. The FICA Tool and HOPE Questions provide serve to assist clinicians in the spiritual assessment process. By examining the research done using these tools, it has been determined that the FICA Tool is easy to use and provides basic data on a patient’s spirituality. The FICA tool is both reliable and valid. The HOPE Questions are easy to use and provides details on a wide range of aspects related to multicultural beliefs. The HOPE Questions is not supported by research thereby it is not valid or reliable. Key Words: spiritual assessment, FICA Spiritual Assessment Tool, HOPE Questions Spiritual Assessment Taking patients spiritual needs into account is an integral component of providing holistic care. Research has linked positive health outcomes with patients whose spiritual needs have been addressed. However, spirituality is not always considered an important part of a patient’s well-being; leading to spiritual assessments not being completed. To aid in addressing a patients spiritual needs, there are spiritual assessment tools available. Some of the tools available include the FICA Spiritual History Tool and the HOPE Questions. This paper aims to examine the above mentioned spiritual...
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...local hospital, I had been buddied with a nurse for an evening shift. We had just had handover from the nurse on the previous shift and among the information handed-over, the patient, in addition to her current diagnosis, also had a history of other co-morbid diseases including heart and blood pressure abnormalities. As such, she was on a number of heart regulating medications which included some beta blockers. As part of time management, we went through the patient's care plan and medication charts to determine what needed to be done and at what time regarding this patient. This guided how we were to execute care during the shift and in a timely manner. Her care plan had indicated that the patient's observations were to be done TDS (three times a day) It was during this process that we decided that it was not necessary, at this point, to take the patient's vital signs as these had been done just a few hours before we had started. When the time for the medication round came, we went to the patient's bed side drawer to collect and give her her medications following the seven rights to medication administration. As a result of our earlier time plan, we did not take her observations. Somehow, the patient asked us curiously why we were not taking her reading as, previously and always before, other nurses seemed to take her readings first? The answer to the patient by the buddy was that we would do that later and I went along with this! I had the same query but did not want...
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...PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Nursing Assessment 1. Part of Nursing Process 2. Nurses use physical assessment skills to: a) Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve b) To identify and manage a variety of patient problems (actual and potential) c) Evaluate the effectiveness of nursing care d) Enhance the nurse-patient relationship e) Make clinical judgments Gathering Data Subjective data - Said by the client (S) Objective data - Observed by the nurse (O) Document: SOAPIER Assessment Techniques: The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the abdomen which is Inspect – Auscultation – Percuss – Palpate. A. Inspection – critical observation *always first* 1. Take time to “observe” with eyes, ears, nose (all senses) 2. Use good lighting 3. Look at color, shape, symmetry, position 4. Observe for odors from skin, breath, wound 5. Develop and use nursing instincts 6. Inspection is done alone and in combination with other assessment techniques B. Palpation – light and deep touch 1. Back of hand (dorsal aspect) to assess skin temperature 2. Fingers to assess texture, moisture, areas of tenderness 3. Assess size, shape, and consistency of lesions and organs 4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep C. Percussion – sounds produced by striking body surface 1. Produces different notes depending on underlying mass (dull...
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...a 66 pack-year history, meaning she smoked the equivalent of 365 packs of cigarettes for 66 years, and occasional drug and alcohol use. LaToya is divorced and lives alone in an older apartment building. Chronic obstructive pulmonary disease (COPD) is a lung disease that limits your airflow. COPD may include chronic bronchitis, emphysema, or both. Chronic bronchitis is the production of increased mucus caused by inflammation. Bronchitis is considered chronic if you cough and produce excess mucus most days for three months in a year, two years in a row. Emphysema is a disease that damages the air sacs and/or the smallest breathing tubes in the lungs. COPD is a progressive disease that makes it hard to breathe and the symptoms will get worse over time. Most cases of COPD occur as a result of long-term exposure to lung irritants that damage the lungs and the airways. Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. One of the greatest challenges for LaToya is to stop smoking. According to the Center for Disease Control (2012), the most important step a smoker can take after getting a COPD diagnosis is to quit. Not only will it make breathing easier, but it will cut down on the risk of severe exacerbations. Health History A health history contains both the subjective and objective data. Obtaining the subjective data is an important first step in treating the patient. The subjective data includes the history from the patient...
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...There is a stigma attached to it that they might be “treated differently.” Moreover, once the patient’s fear prevails and continues it is more likely that their health care issues and concern will not be properly addressed and will develop to a substandard prognosis. There are also some instances where physicians are the ones who feel reluctant in taking the initiative to obtain the necessary information about their patient’s “social and sexual history.” Therefore, patient’s apprehension and physician’s lack of initiative is the phenomena that serve as an obstacle in obtaining the most pertinent information needed to assess their patient’s health status and to properly diagnose their health complaint (Tortelli,...
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...In order to provide patient-centered care, nurses must incorporate the patient as a whole. They have to be aware of the differences amongst their patient’s expressed needs, preferences, and values (American Association of Colleges of Nursing, 2008). Cultural beliefs and practices are vital factors to consider when assessing the patient for these things. If a nurse were to just take care of everyone based upon his or her own beliefs, the care provided would not be considered patient-centered at all. So how does one assess a patient’s cultural affiliations? The Heritage Assessment Tool is a great questionnaire that will guide a nurse into the world of the patient. It allows the nurse to look at the patient as a whole, not just looking at his or her medical condition. It assesses the patient’s family history in regards to culture, religion, family, and surroundings. The questionnaire was used to interview a member from three separate cultures. This paper will describe some differences and similarities in health traditions amongst the Muslim, Latino, and Western cultures. The African race is made up of many cultures. B. Babale is a male whom this writer interviewed. His and his family’s beliefs correlate with the Muslim religion, like the majority of the Northern African population. He was born in America; however his parents came here in 1981. Him, and his family have a strong belief in prayer and they have many customs with prayer. They pray many times a day (usually...
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...Phase The preoperative phase is the time period between the decision to have surgery and the beginning of the surgical procedure. For some patients, the preoperative period may last for months, during which testing and other procedures may be done. For an emergency, such as an appendectomy, the preoperative period may last only a few hours. During the preoperative phase, preadmission testing is done to assess health history, family medical history, and any known allergies to medications. During which time explanation of the surgical procedure and patient education is taking place. Patient education advises the patient on pre-surgical preparation such as bowel preparation, nutritional and fluid intake the day before the procedure and when to stop eating, and how to proceed with medication therapy the day before surgery. Diagnostic testing includes ECG monitoring, blood testing and vital signs. The trauma of surgery can greatly be relieved by psychological preparation of the patient before surgery, so during preadmission testing psychological evaluation is also taking place to assess the patient for any fears or anxiety related to the surgical procedure. The nurse should discuss techniques to aid physical recovery and ways to lessen the pain and anxiety that is related to surgery. This phase is the most crucial and it is what sets the pace for the entire experience and helps in maintaining patient safety. Psychological preparation is very important for the patient and for...
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...Running Head: RADIOLOGY TECHNOLOGISTS ROLE Radiology Technologists Role in Quality Patient Care and Safety Keiser University Abstract I never really sat down and realized how important patient care really was going to be to my job. I always just thought of it as just taking pictures of the bones. Come to find out there really is a whole lot more to it than what I thought. Quality patient care is very important from the way that we communicate with the patient all the way to the time they go home and or are released from the hospital or care. There are several protocols and procedures that we are required to follow and abide by. These are just done to ensure that neither the patient nor we get hurt; and that everything is done in a safe manner. The patient’s life kind of still lies in your hands sometimes. Radiology Technologists Role in Quality Patient Care and Safety How would you feel if the Radiology Technologists that was taking care of you didn’t know what they were doing? I know that I wouldn’t feel comfortable and would probably ask to have someone else take care of me. Which as a patient we have that right; but there are roles and guidelines that the Radiology Technologists have the duty to follow as well. The American Society of Radiologic Technologists has made a Code of Ethics that should be followed. These Code of Ethics...
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...A CLINICIAN’S HANDBOOK Talking With Your Older Patient NAT I O NA L INS TITU TE O N AGING NATIONAL I NS TI TUTES OF HEA LTH DEPARTM EN T OF HEA LTH A ND HUMA N S ERV I CES Contents Foreword 1 1. Considering Health Care Perceptions “I’m 30 . . . until I look in the mirror.” 3 2. Understanding Older Patients “Tell me more about how you spend your days.” 6 3. Obtaining the Medical History “What brings you here today?” 13 4. Encouraging Wellness “I’d like you to try this exercise routine.” 19 5. Talking About Sensitive Subjects “Many people your age experience similar problems.” 23 6. Supporting Patients With Chronic Conditions “Let’s discuss living with . . .” 36 7. Breaking Bad News “I wish I had better news.” 40 8. Working With Diverse Older Patients “Cultural differences, not divides.” 44 9. Including Families and Caregivers “What would you like your family to know?” 48 10. Talking With Patients About Cognitive Problems “You mentioned having trouble with your memory.” 51 11. Keeping the Door Open “Effective Communication” 58 Publications At-a-Glance 60 Services At-a-Glance Tear-Off Card Foreword Good communication is an important part of the healing process. Studies find that effective physician-patient communication has specific benefits: patients are more likely to adhere to treatment and have better outcomes, they express greater satisfaction with their treatment, and they are less likely to bring malpractice suits. Research also shows that...
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...patient interview. • Conduct a thorough medication history. • Compare and contrast the different patient interview approaches in various clinical settings. • Adapt the interview technique based on the needs of the patient. Key Terms • Active Listening • Rapport • Empathy • Open-Ended Questions • Leading Questions • Probing Questions • Nonverbal Communication • Chief Complaint • History of Present Illness • Pertinent Positive • Pertinent Negative • Past History • Medication History • Family History • Personal and Social History • Review of Systems • Physical Exam • QuEST/SCHOLAR-MAC Introduction The patient interview is the primary way of obtaining comprehensive information about the patient in order to provide effective patient-centered care, and the medication history component is the pharmacist’s expertise. A methodological approach is used to obtain information from the patient, usually starting with determining the patient’s chief complaint, also known as the reason for the healthcare visit, and then 2 Chapter 1 / The Patient Interview delving further into an exploration of the patient’s specific complaint and problem. A comprehensive patient interview includes inquiring about the patient’s medical, medication, social, personal, and family history, as well as a thorough review of systems and possibly a physical examination. The medication history is the part of the patient interview that provides the ...
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