...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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...Course Project Milestone 1: Health History Form Your Name: Eva Hollingsworth Date: 1/28/14 Your Instructor’s Name: Professor Butler Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language. Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith” When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment. Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” BIOGRAPHICAL DATA (10 pts) | | Date: | 1/22/14 | Initials: | V.H. | Age: | 40 years old | Date of birth: | August 10,1972 at 0801 in the am | Birthplace: | Einstein Hospital in Philadelphia, Pa | Gender: | Male | Marital status: | Married anniversary March...
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...Health history Function- Mental state n physical state for well being Intuition- gut feeling- from experience, Index of suspicion- asking question with reasons by comparying the situation and condition of the patient. They go hand in hand which come through experience. Health history S- symptoms through pqrst ( provoking and palliative) Provoke- what causes symtoms to be worst? Palliative- what causes symtoms to better? Q- Quality it means description. Open ended question Describing the symptoms. 1.What are you feeling? funny 2. Descibe funy? What is that mean? A bit tied.. 3. had you feeled before? 4. how is different from before? Feeling going from arms. R- Region and radiation Which art of your body are you feeling the symtoms? Where are you feeling tited ness? Around here- that means not localized. Is that your chest? Ask yes no for calrification’ Radiation- where else are you feeling the symptoms? Going up around neck and arms S- Severity (0 to 10) how severe is yoiur symtoms? Its about that 8. 0 no pain and 10 worst pain Does it stop doing anything? Daily activity T- time of actual symptoms When does it normally occur? How long does it last normally? Normally less than half hour but this is long Is it on and off? Constant or on or off? A- allergy- penesil, antibiotic, lacto biopsycho social model- nurses for allery NKA-nurse NKDA- doctor Burden- social worker Home- equipment Stair- ot to repair to help them Food to be...
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...all-blacks town in Mississippi. Mound Bayou was well known for its premium cotton. Mound Bayou was also known for its hospital, cotton gin, and famous oil mill. Planters that was near Mound Bayou would send their cotton from Mound Bayou stations. A very small black colony impacted by falling farming prices, natural habits of business going kind of wrong, and hostile race similarity. The migration movement was led by Isaiah Montgomery, former partner of Davis Bend. Purchased from the Louisville, New Orleans, and Texas Railroad (L,NO,&T). Mound Bayou bordered a new rail line between Memphis,Tennessee and Vicksburg. Mound Bayou was founded in 1887 as we already know. Two former slaves, Isaiah T. Montgomery and Benjamin Green. The history of Mound Bayou began with Ben Montgomery, father of Isaiah Montgomery. Ben over the years learned skills that would come in handy in the long run. He purchased two plantations on land once owned by Joseph Davis known as Davis Bend, and this was all done after the civil war as mentioned in my notes. Cotton was a positive and negative thing to the economy of Mound Bayou. Cotton also was the best production in Mound Bayou. African Americans owned businesses and freedom social issues. The economic significance of Mound Bayou was that L, NO, and T railroad which Mound Bayou depended primarily on; helped to transport the production of cotton, timber, and corn. As we already know, Mound Bayou was all-black town or community. The African...
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...interaction with your fellow students? * How did participating in this discussion help in your understanding of the Discussion Board task? * What approaches could have yielded additional valuable information in the students' networking? * What is still unclear after the discussion with your classmates that needs to be clarified? During week ones discussion board assignment, we discussed the different types of health insurance billing and reimbursement methods. This discussion board assignment required taking the time to research the history of health insurance and how it has evolved over the years to the system that we know it as today. By utilizing the discussion board portion of this class, I was able to learn many things from my classmates’ postings. I learned the many different methods of healthcare reimbursement that is still currently used today. I learned the history of health insurance, and why it was developed for the patients in the first place. I also learned many different views and opinions of my classmates that allowed me to reconsider and further educate myself on the views of the future of the healthcare industry. The most compelling points that I absorbed from reading my classmates postings was reading every ones ideas and opinions regarding the future of the healthcare insurance industry. It was interesting to me to learn the different aspects of the universal health care plan that is in motion right now that I never would have considered before this...
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...Humanities and Sciences are both essential in each and everyone’s lives. Sciences are important as it ensures new possibilities and ideas for our society. Science can be defined as “the study of the physical, biological aspects of the world.” 1 It is very much like reality. Technology, medicine, business are all science-related courses that are essential in our daily lives in the future. Humanities, on the other hand, are more about “content with not knowing, but rather, practice questioning and questioning, never settling on one single answer, because the truth is just based on different perceptions.” 2 Humanities facilitate critical thinking and perspectives, and such subjects include literature, history, social sciences and the cultural identity of each country. Both the humanities and the science are correlated and work hand in hand. “Both the sciences and the humanities seek understanding; both offer explanations of various bits of the world.” 3 The Ministry of Education (MOE) too agrees that students should be exposed to both the humanities and the sciences. MOE has changed the Advanced-level syllabus on 2006. Each junior college student is required to take a minor in either the arts or the science combination. According to MOE, “Most people will change jobs at least a few times in their careers, sometimes switching to jobs in entirely new fields. What will give advantage is being able to adapt to new situations, to draw on insights from different fields, and to think...
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...Readings for American History Since 1877 Historiography in America...................................................................................................................................................... 2 How to teach history (and how not to) ................................................................................................................................ 6 How Ignorant Are Americans? ........................................................................................................................................... 9 The West ............................................................................................................................................................................... 11 The Education of Native Americans ................................................................................................................................. 11 Bury My Heart at Wounded Knee .................................................................................................................................... 15 Prostitution in the West: .................................................................................................................................................... 17 The Gilded Age ..................................................................................................................................................................... 21 The Duties of American Citizenship ...........................
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...our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare. Our tracer patient was a 67 year old female who presented with a fever and drainage five weeks after an open hysterectomy. She was admitted for a suspected postoperative infection,. She underwent another surgery to treat the abscess that formed from the initial surgery and had a central line inserted for long-term antibiotics. She is scheduled to go home with home health overseeing her antibiotic therapy. This tracer patient has shown that there are areas of our patient care that we need to improve upon in order to be in compliance with the Joint Commission standards. According to The Joint Commission (2014) compliance with standard PC.01.02.03 requires that a history and physical examination be done within 24 hours of inpatient admission and prior to surgery. In the case of this tracer patient, the history and physical was completed more than 72 hours after admission. Further, this patient underwent surgery two days after admission, prior to the completion of a history and physical exam. The history and physical examination is a very important tool in a patient's care. It provides information...
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...MARICOPA COUNTY COMMUNITY COLLEGE DISTRICT PATIENT PRIVACY GUIDELINES For MCCCD Health Care Integrated Educational System The Maricopa County Community College District has cooperative agreements with over 500 agencies for the clinical training of its students enrolled in all health-care fields and programs. To ensure that MCCCD students, faculty, and staff involved in those programs understand the patient privacy requirements of those clinical sites and of applicable law, including the Health Insurance Portability and Accountability Act of 1996, MCCCD offers this guidance for those persons to ensure compliance with those requirements. Note that the discussions, uses or disclosures discussed below encompass written, verbal, or electronic communications. |DO’S |DON’T’S | | | | |Do sign the MCCCD Faculty/Staff/Student Confidentiality Agreement before |Don’t discuss, use or disclose any patient information while in the | |any involvement in a clinical program. |clinical setting unless it is part of your clinical assignment. | |Do attend MCCCD training or in-classroom clinical instruction on |Don’t remove any record from the...
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...HEALTH ASSESS STUDY 1. Subjective vs. Objective data a. Subjective: The health history, symptoms i. What the patient tells you ii. Chief complaint to Review of systems b. Objective: What you detect during the examination, all physical examination findings 2. Attributes of a Symptom c. Onset: when the sign or symptom began d. Location: Where the sign or symptom is located iii. Where exactly is the headache? Can you point to it? Does it radiate? e. Duration: how long the sign or symptom has been going on? iv. Does the headache come and go? Is it nonstop? What time of day is worst? f. Characteristic symptoms: what the symptom feels like, what describes it, and its severity. v. How does the headache feel? Is it throbbing? Sharp? Stabbing? Describe it. Rate it on a scale of 1-10. g. Associated manifestations: what else is going on when the patient experiences the sign or symptom vi. Does anything else happen when you get the headaches? Blurred vision? Nausea? Vomiting? Seizures? h. Relieving factors: anything patient has done to relieve the headache. vii. Have you tried cool compresses? Rest in a dark room? Did it work? i. Treatments: any interventions the patient has previously tried. viii. Has the patient seen a health care provider? Tried any remedies: medications, acupuncture, Did they work? 3. Interviewing technique ...
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...65 or older. “Nearly 70 percentages of dementias are Alzheimer’s, and over 4.5 million Americans have it” (www.alz.org). This disease happens in older people, but a small percentage that can affect those in their middle age. One of the greatest risk factors that increase Alzheimer’s in family history is ages, and genetics. Alzheimer’s develops in genetic, lifestyle, and environmental work factors that cause this disease process. “Research shows that Latinos and African Americans in the United States have higher rates of vascular disease for developing Alzheimer’s”. (www.alz.org). If someone in your family has Alzheimer’s such as a brother, sister, or parent, they are more likely to developing the chance to getting the disease. There are two stages to having the disease, early onset and late onset. The early onset stage affects a small percentage of people under the ages 35 to 65. The early onset stages are usually inherited from a family history meaning a greater chance for developing the disease. The person tends to deal with forgetfulness, mood swings, performing daily tasks, and concentrating. The late onset stage developed after the age 60 with no genetic or family history involved. This stage of the disease is a long progress that could take several years for a person to experience severe confusion, behavior changes, difficulty eating, swallowing, and loss of awareness. It is also the final stage of Alzheimer and approaching...
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...Shanae McKenzie Unit 14 P3: Describe the investigation that are carried out to enable the diagnosis of these physiological disorders Coronary Heart Disease Diagnosed This is when the patient refers themselves to a health professional, the will go to their GP. The person will notice something different about their body and themselves such as feeling breathlessness. Professional referral This is when the doctor will examine a patient and be extremely anxious about the diagnosis for immediate attention by hospital doctors. The doctor will see the patient a few times before deciding on referral to a consultant or specialist in that field of medicine. It may be a server of weeks before the patient can actually be seen by a specialist consultant....
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...and complete the following for your assignment: Trace the major historical developments of hospitals in the United States. Identify the major historical events of hospitals in a country outside of the United States. Compare and contrast the history of both countries' hospitals, and discuss which one you feel has evolved to more effectively provide patient care. Be sure to provide rationale for your choice of which hospital more effectively provides care. Abstract No matter what part of the world one may live in, there is a rich history within those cultures. There are also history backgrounds of their hospitals and how they came to be. The objective of this project is to take a closer look into the historical developments of hospitals within the United States and India and based off their developments, which of the two grant superior effective care. The development of health care facilities has a long history no matter what part of the world they are in. Many techniques and standards have been lost and gained throughout the years. What all hospitals should always strive for is discovering new and innovative ways to perform each and every aspect of their job more effectively throughout the course of their history. United States In the course of the 19th century, a large part the population inside the United States delivered children, suffered from a variety of illnesses and conducted surgery in the interior of their homes and few...
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...have been exposed to Chinese medicine through immigrant migrating from china (history of Japanese acupuncture). The first record of Japan being introduced to acupuncture was when a Chinese monk named Zhi Cong; Zhi Cong traveled...
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...Demographics: Patient 001 is a 16 years old Caucasian female who comes in today with her mother for a comprehensive mental health evaluation. Recent Travel Outside U.S. - Recent Exposure to illnesses: Patient denies any recent travels outside the United States. Chief Complaint: She complained of having self-harming thoughts and seems to cut her legs with scissors whenever she gets frustrated. History of Present Illness: She reports that she cuts herself at least once a week, waits for it to heal and then cut herself again. She cuts herself when she feels alone or frustrated. She reports feeling guilty when she is done cutting and cleaning herself up. The patient illustrates that she frequently feels nervous and cuts herself as punishment. Her anxiety depends on what she is doing, especially when she gets nervous. When anxious, she sweats a lot with shaky hands, heart racing and the feeling to throw up. The patient is occasionally afraid of being left alone and reports feeling uncomfortable around people she is not familiar with. She denies any history of obsessional or ritualistic behavior. She admits to having a good relationship with parents, but reports that she is occasionally hesitant to talk to her parents and denies separation anxiety. She admits to being self-aware, but denies feeling of paranoia....
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