Hilary Lloyd and Stephen Craig 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 they must also be able to use their listening skills to gather the important facts the patient gives them. When asking questions, Craig and Lloyd suggest trying to avoid the use of technical terms and communicating in words that can be understood by the patient. Knowing how to convey the questions being asked can be important and can illicit a great deal of information and can also bring out very important details about their history. Paying attention of the nurses to the use of non-verbal communication, such as proper eye contact, facial gestures and body posture should be considered during the history taking process as well. Once a good relationship with the patient is established, then the other parts of the history that may seem uncomfortable for the patient as well as the nurse will be easier to come across when the time comes during the process.
History taking should start with the chief complaint. By using an open question, the nurse can gather the basic information of what the main problem the patient is experiencing. After that, using more specific questions such as symptoms of different parts of the body that the patient is feeling along with further clarification of said symptoms like the time of onset, duration, frequency, et cetera are all vital information for the history.
Moving on to the past medical history (which includes allergies) if there is any, is the next step once obtaining the information needed for the main complaint. There you can acquire information of any medication they are taking which can include prescription and over the counter medications. Asking about family history can also give information needed in order to guide the proper plan of care for the patient starting from the immediate family and outward. Craig and Lloyd mention the subsequent part of patient history is that of the “patient’s ability to cope with a change in health depends on his or her social wellbeing” (p. 46). The patient’s day to day activities physically and socially is important to know and can be affected due to the current illness. On the other hand, their social history which includes their job may be the cause of past or current illness as well such as smoking, drinking, drug use, and even sexual activity that can cause illness itself that affects the patient future health.
The nurse using their critical thinking skills should