In this article Lloyd and Craig outlines the process and rationale for taking a health history. Also, this article provides different methods to taking a comprehensive history. Summary of Article Taking a successful history includes preparing the environment, effective communication skills, and order. It is the most important part of patient assessment.
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 careful evaluation of patient needs. To avoid receiving incomplete information, allowing adequate time is essential to complete the history. 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 and creating a meaningful nurse-client relationship and should be performed in a professional, non-judgmental manner by performing a cultural assessment, because things like eye contact, handshakes, or posture may have different meanings in various cultures.
It is also very important to assess health beliefs and practices since a person’s perceptions about health and illness are greatly influenced by one’s heritage and culture. After introducing yourself to the patient, maintaining good communication is critical.Patients must be allowed to tell the story their way while the nurse actively listens. This is a basic part of the communication process and is the most important interactive skill because it means paying undivided attention to what the patient says and does (D’Amico & Barbarito).
The patient should not feel rushed as this could adversely affect building of the nurse-client relationship. Communication by the nurse should consist of language that is not hard to understand and should incorporate both verbal and non-verbal skills.Examples include, maintaining eye contact, showing interest by posture, using hand and facial gestures, appropriate rate, tone and volume. According to D’Amico & Barbarito, giving full attention to verbal and nonverbal messages is called attending and may be as much as 93% of the message that the client sends.
After the introduction, the nurse should obtain the patients consent and determine how the patient prefers to be addressed as well as gather demographic or biographic information including age and occupation, marital status, religion, etc.Another important factor of communication is asking open-ended questions. These enable the nurse to elicit more information from the patient. After which a focused assessment with specific questions can be asked to clarify previously obtained assessment data, gather missing information about a specific health concern, identify or validate possible nursing diagnoses.
According to Lloyd and Craig, summarizing the history back to the patient allows the nurse to be sure he or she has the information correct.According to Macleod’s clinical examination (2005), the history should be done in sequence beginning with the presenting complaint, but says it is not necessary to adhere to this rigidly. In the article by Lloyd and Craig, focusing on cardinal symptoms regarding overall health and systems is more important than the diagnosis, ensuring that no valuable information is overlooked. Negative responses are also said to be equally important.
Reviewing past medical history provides crucial background information according to Lloyd and Craig and should include dates, diagnoses, management of illness, etc.D’Amico and Barbarito states that the past medical history includes information about childhood disease; immunizations; allergies; blood transfusions; major illnesses; injuries; hospitalizations; labor and deliveries; surgical procedures; mental, emotional, or psychiatric health problems and the use of alcohol, tobacco and other substances. Assessment of a client’s mental status and coping strategies should be explored as they are also part of well being. Evaluation This is a well written article.The grammar used therein is easily understood to the point that a nonprofessional could comprehend the information almost effortlessly.
The transition from one paragraph to another seems to flow in sequence from the beginning to the end. Upon reading the article, I also feel that knowledge about how to properly conduct a health assessment has been broadened as well as the recommended sequence but obtaining of the correct information is more important than following a specific order.All parts of this article appear to be equally relevant and interesting. Conclusion This article provides practical insights to obtaining a health history as well as various strategies to follow that will ensure the collection of accurate data. Following the guide outlined in the article along with experience will enable the nurse to build needed confidence to go from novice to expert.
