A Guide to Taking a Patient's History - Assignment Example

A guide to taking a patients history Introduction ‘A guide to taking a patients history’ is an article published in Nursing Standard in the December,2007 issue, written by H. Lloyd & S. Craig. In this article, Lloyd & Craig provide an overview of process of taking a history from a patient. There are different principles to follow while gathering information from the patients. The initial aspects involved in history taking are preparing the comfortable environment and use of apt communication skills. The article has also focused the sequential nature for capturing history where the author has described presenting complaint and different types of histories which are necessary to evaluate a patient. The rationale for taking a comprehensive history is also discussed. Knowledge obtained from detailed investigation would help in correct diagnosis and treatment of the patient. Summary Over the years the nursing field has developed in countless ways in terms of challenges and roles leading to enhancement in nurses’ assessment skills. Grabbing accurate information from the patient about the underlying problem in a systematic, sensitive and professional manner is one of the important health assessment tools. The description of the problem given by the affected individual may reflect different underlying mechanism of the medical condition of the patient. Due to inapt method of treatment for a patient without knowing his history can give rise to a medical error and fatal medical mishaps. Therefore, it is necessary to have full and comprehensive approach while taking history of a patient. The nurse should begin the study of the past events with setting the appropriate comfortable environment, self introduction, stating the purpose of taking history and obtaining consent from the patient (Lloyd & Craig, 2007). Then, connection with the patient should be commenced with basic knowledge of demographic details, such as name, age and occupation of the patient. The article has also focused the sequential nature of the history taking process. History taking should start with the presenting complaint with an open question, which could be narrowed down to specific details according to the manifestations to get clear picture. Then the attempt should be made to know past medical history and mental health status of the patient. This should be followed by enquiring about medication history, family history, social history, sexual history, occupational history. The narrative from the patient should be ended with the systematic enquiry. According to Lloyd (2007), “It involves systematic questioning of symptoms relating to cardiovascular, respiratory, gastrointestinal, genitourinary, locomotor and dermatological aspects and might yield important clues about the cause of the presenting problems” (p. 48). Further information could be collected from a third party and then, the report should be summarized. The article also states that the line of communication should be open in the beginning of the session; while the closed questions are asked at the end to extract more details to get clear picture of the patients story. The history report should be rechecked and shared with the patient for the agreeable record to facilitate interaction between patient and nurse and understanding the client’s needs. This would assist in decision making related to diagnosis and treatment. Evaluation This is an interesting article, describing an overview of process of taking a history from a patient. History taking is one of the useful tools to divulge specific characteristics and symptoms associated with medical cause. After reading this article, a deeper insight into understanding of nurse’s vital role in delivering precise history information to the health care practitioner is unfolded. The reporting of an exact history can provide invaluable advice to improve medical condition of a patient. The article is written in such a way to provide a step-by-step guidance of the history taking process. The author has attempted to provide a clearer picture and understanding of how each step in history taking should be performed. The journal author provides a review of the process in a box format, thus lending to the article being easily read. The method of history taking is clearly outlined, and easily followed. However, the author has not mentioned the critical thinking of historytaker which would assist in taking the history from uncooperative as well as from the patient who are not able to explain the symptoms properly. By manipulating the steps, the health car provider can extract maximum information. The author has stated the examples of unhelpful interview techniques which advice history takers to follow a cautious questioning and reacting approach. The knowledge from this article can be relevant to both nurses and practitioners who are historytakers because it provides a clear outline of the assessment process. This article is instrumental in providing clear guidance for freshers and experienced history takers. Conclusion This article focuses on the systematic and comprehensive approach of taking a history from a patient. The article has discussed various aspects of history taking including preparing the environment, interaction abilities and the importance of sequence. In addition to this, it has expressed the need for a validated training course to judge competency of a nurse in history taking. The knowledge about the (Nursing and Midwifery Council) NMC Code of Professional Conduct regarding competence, consent and confidentiality should be displayed by the historytakers. The freshers should report the history of their clients according to the NMCs guidance on record keeping. Reference Lloyd, H. & Craig, S (2007). A guide to taking a patients history. Nursing Standard, 22 (13), 42-48. Retrieved February 20, 2008 from CINAHL Plus with Full Text database Assessing and managing patients with musculoskeletal conditions Introduction ‘Assessing and managing patients with musculoskeletal conditions’ is an article published in Nursing Standard in the September, 2007 issue, written by Nicola Judge. In this article, Nicola provides an overview of the anatomy and physiology of the musculoskeletal system. The complaints associated with affected musculoskeletal system are most prevalent. This article also focuses on various assessment techniques, along with the underlying principles of nursing care management in both acute and primary care settings. Summary Over the years the nursing field has developed in countless ways in terms of challenges and roles leading to enhancement in nurses’ assessment skills. The musculoskeletal system consists of bones, muscles and joints. Almost all of the body mass is made up of the musculoskeletal system. This system is responsible for executing number of duties like framing the body’s shape, support and protection of soft tissue structures such as the brain, heart and lungs, movement, breathing, storage of calcium and phosphate in bone, the production of red blood cells, white blood cells and platelets in the bone marrow (haematopoiesis). The injury or disorder to any of the parts in the system can lead to musculoskeletal complications resulting in patient trauma or elective surgical admission. The simple to complex medical conditions include osteoarthritis, rheumatoid arthritis, osteoporosis, fractures, sports injuries etc. Capturing accurate information from the patient about the underlying problem in a systematic, sensitive and professional manner is vital to understand physiological, psychological and psychosocial status of the patient. The history taker should obtained information from the client regarding symptom onset, pain, swelling, stiffness, deformity, weakness, numbness, and any functional difficulties (Judge, 2007). The distinguishing characteristics of each type of pain are important to recognize underlying nature of pain. This article also focuses on various assessment techniques, along with the underlying principles of nursing care management in both acute and primary care settings. Comprehensive assessment of pain is done by the standardized approach called PQRST to know pain stimulus, the quality and quantity of pain, the region and radiation of pain, the severity of pain, and the timing of pain. According to the patient’s ailment, the comprehensive examination of patient begins with a general inspection, followed by a regional joint examination and finally range of movements are checked. Acute soft tissue injuries are handled by giving instructions for rest, ice therapy, compression, and elevation to reduce swelling. Injured and post operative patients should be carefully monitored by nurses for early diagnosis of neurovascular complications including thrombosis, pulmonary embolism, chest infection, pressure ulceration, constipation and urinary stasis (Judge, 2007). The choice of treatment design is based on the nature (acute or chronic), type, quality, degree of pain and sensitivity to medication. Pharmacological treatments mainly include analgesics like non-steroidal anti-inflammatory drugs, opioids, paracetamol and local anaesthetics as well as antidepressants. The supportive treatment strategies such as positioning, distraction techniques, appropriate exercise after rest phase and massage are very useful in such patients. Evaluation This is an interesting article, presenting an overview of musculoskeletal system. After reading this article, a deeper insight into understanding of our body framework associated with the musculoskeletal system is developed. The discourse help by providing a clearer picture and understanding of how each different injury led to a different outcome. This writer has explained the anatomy and physiology of bones, muscles and joints in detail, and the significance they presented to each injury. The journal author provides a review of the musculoskeletal conditions that commonly result in patient trauma or elective surgical admission, thus lending to the article being easily read. This article focuses on the systematic and comprehensive approach of taking a history from a patient suffering from pain. This article also includes an assessment of musculoskeletal patients with standardized PQRST approach, though detail pain scale measurements are not explained by the author. This assessment is clearly outlined, and easily followed. The author has stated fairly pharmacological and nonpharmacological treatment strategies. The author has not focused enough on the supportive therapies which also play very important role for the management of pain. The knowledge from this article can be relevant to both nurses and practitioners because it provides a clear outline of the assessment and management process. Conclusion This article provides a presentation of patients with musculoskeletal conditions in acute, chronic and postoperative cases. In addition to the anatomy and physiology of the different parts of musculoskeletal system overviewed, the complications are discussed. A variety of injuries or disorders leading to musculoskeletal malfunctioning are thoroughly discussed along with the situations when they could happen to provide valuable knowledge. The author has clearly stated that the history taker should obtained information from the client regarding symptom onset, pain, swelling, stiffness, deformity, weakness, numbness, and any functional difficulties. . In addition to this, the writer has expressed the need for a registered nurse to have detail information about the working of the musculoskeletal system so that they can play key role in assessment and management of such patients to ensure best health outcome. The treatment design from management with analgesics and physiotherapy to surgical intervention is briefed. The treatments and interventions discussed are applicable to nursing assessment, clinical practice, and early diagnosis of complications. Thus, this article has reviewed, all valuable knowledge to develop wisdom to assess, treat and manage patients suffering from musculoskeletal injuries and dysfunctions. Reference Judge, N. L. (2007). Assessing and managing patients with musculoskeletal conditions. Nursing Standard, 22 (1), 51-57. Retrieved February 20, 2008 from CINAHL Plus with Full Text database References Lloyd, H. & Craig, S (2007). A guide to taking a patients history. Nursing Standard, 22 (13), 42-48. Retrieved February 20, 2008 from CINAHL Plus with Full Text database Judge, N. L. (2007). Assessing and managing patients with musculoskeletal conditions. Nursing Standard, 22 (1), 51-57. Retrieved February 20, 2008 from CINAHL Plus with Full Text database Read More