A guide to taking a patient's history - Essay Example

Download file to see previous pages ‘A guide to patient’s history obtaining Nursing’ article by Lloyd and Craig investigates the approach of gathering history of a patient. The guide identifies the procedure and reason of patient’s history obtaining, the significance of environment preparation and how efficient skills of communication aid in the taking of accurate history. Article summary Correct patient history is crucial because it provides the doctors or nurses and healthcare management with the effective information required in carrying out their assignments. The environment preparation offers patient safety, correctly equips them and eliminates any form of patient or nurse distractions during history taking process. The patient may feel uncomfortable talking over some sensitive matters if some distractions occur in the environment, or the nurse seems not to be attentive. The setting should be private to make the patient confident to give private information without reservation. The nurse should ensure respect for the patients, which involves respecting the values and beliefs and privacy, confidentiality and dignity of the patients, and the capacity to be non-judgmental and highly professional throughout the process. Effective communication skills are crucial to allow obtaining of a comprehensive history, while the medical practitioner should obtain patients consent before the commencement of the intervention. After obtaining the patient consents, the nurse should follow the below overall standards when collecting patient’s information. First, Introductions are crucial for the creation of patient-nurse relationship and mutual trust and to help set an interview process tone, and investigate how the patient prefers to be addressed. Pay attention to the patient’s history as this provides a systematic order of information. Closed questions offer additional information and enlighten patient’s story. Clarification, which entails recalling back to the parson and comprehension of the history, comments and disease symptoms, is crucial. After complaint presentation, the nurse should take the medical history of the patient and investigate other related histories and records of the patient. It also provides crucial health information background such as cancer history and about diagnosis, sequence, disease management and dates. Mental health history investigates whether the patient has experienced any mental challenges in the past. Investigate the present coping mechanisms of the patients including anxieties over health challenges (malignancy suspicions, future surgery, test outcomes) or advanced mental challenges like bipolar disorder. Medication history is crucial to investigate the previous and current medication that the patient may be using. For instance, the source and form of medicine used, whether the medicines were prescribed by a doctor, bought from pharmacy or acquired from other sources such as herbal medicine and homeopathic remedies. Family history should be established because it can provide a significant source of familial conditions like cerebral malaria, dementia history, asthma and diabetes history, which might aid direct patient healthcare management. Social history – experts agree that a person’s capacity to cope with health alterations depends on his social welfare. The nurse should investigate the function level and any long-term functional change due to illnesses, (Lloyd & Craig, 2007). The nurse should investigate the patient’s family relationship, social membership and other social support networks. Sexual history covers sexual health, and some of the sexual infections that the patient may have experienced. For instance, in men investigate about past infections of urinary tract and STIs and possible treatments offered. In females, explore date of menstruation, menarche regularity and characteristic of pregnancies, abortion, life births and periods as well as risks of STIs infections, (Lloyd & Craig, ...Download file to see next pagesRead More