...guide to taking a patient’s history” is an article which was written by Hiliary Lloyd and Stephen Craig, published in volume 22, issue 13, of Nursing Standard in December 2007. Lloyd and Craig describe the process of taking a health history and explain how environment and other factors affect the accuracy of the health history obtained. This article provides different methods to taking a comprehensive history and the order in which to do so. Summary of the Article Taking a patient’s health history is an integral of patient assessment and it is important that nurses hone their assessment skills while expanding their role as a nurse. Before a health assessment is taking the nurse must first have informed consent from the patient. While taking a health history it is important to choose the right environment, free from distractions if possible and safe for the patient and nurse. The nurse should convey respect for the patient as a person and maintain a level of privacy and dignity. Good communication skills are essential; the nurse must introduce herself to the patient, develop a rapport with the client by being professional, friendly and show interest by actively listening to the patient, the patient should not feel rushed or hurried. Nurses should refrain from using medical jargon when possible and utilize verbal and non-verbal communication skills. It is important to consider culture when taking a patient’s health history. Perform a cultural assessment of the patient by paying...
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...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...
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...Journal Article Review Kim Watson Chamberlain College of Nursing NR 305 Health Assessment Professor J. Deibel Spring B 2014 Journal Article Review Introduction ‘A guide to taking a patient’s history’ is an article published in the nursing standard Journal, volume 22, issue 13, dated December 5, 2007, written by Hillary Lloyd and Steven Craig. In this article, Lloyd and Craig describe the practice of obtaining a patient history in a systematic way, importance of communication skills, preparing the environment, and explaining why a thorough assessment is indispensible. Summary of Article Obtaining a patient’s history is of utmost importance, for the nurse or healthcare provider, when conducting a patient assessment. It is during this time the patient presents valuable and pertinent information. Also, it is at this time a relationship is evolved between the nurse and patient. Prior to taking the history it is important to prepare the environment. The nurse may come across many varied environments. Such as, patient’s homes, emergency room, clinics, community settings, and different areas of the hospital. Having all needed equipment accessible and area to avoid interruption is important. The environment should support safety for both the patient and nurse. Making sure enough time is allotted to conduct the assessment is stressed. “Not allowing enough time can result in incomplete information, which may adversely affect the patient’s care”(Lloyd...
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...Journal Article Review Introduction “A Guide to Taking a Patient's History,” an article written by Hillary Lloyd and Stephen Craig, which was published in volume 22, issue 13 of the Nursing Standard journal in December 2007 issue. The article provides an overview of professional processes involved in attaining patient’s history, emphasizes preparation of a comfortable environment, and exemplifies the significance of using effective communication skills to assist practitioners with obtaining a comprehensive and an accurate patient history while using a structured systemic approach in a variety of settings. Summary of the Article “Taking a patients history is arguably the most important aspect of a patients assessments, and is being undertaken by nurses” (Crumbie, 2006, as cited in Lloyd & Craig, 2007, p. 42). An accurate and comprehensive patient history is imperative and “cannot be overstated” (Crumbie, 2006, as cited in Lloyd & Craig, 2007, p. 42) since it provides clinicians with the most essential information needed to establish an effective and a patient focused plan of care. Lloyd and Craig recommends preparing a comfortable environment and using effective communication skills in a logical and systematic approach to begin this process to achieve the best patient outcomes. First, the nurse should begin with preparing the environment by ensuring it is easily accessible, well prepared, safe for patients and or/and their family member(s), and preferably in a location where...
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...Journal Article Review Chamberlain College of Nursing NR 305 RN Health Assessment Journal Article Review Introduction “A guide to taking a patient’s history” was written by Hilary Lloyd and Stephen Craig. The article was published in the December 5, 2007 issue of Nursing Standard. The article discusses the process of taking a patient history, preparing the environment, communication, and the importance of order. Summary of Article The patient history is an important part of the patient assessment that nurses conduct. The article provides steps on how to take a full and detailed patient history. The first step before obtaining a patient history is obtaining consent from the patient. The patient must be able to provide consent if they are able to act on their own free will and are able to understand what they have agreed to. The next step is preparing the environment. Preparing the environment includes: ensuring that the environment is safe for both the patient and the nurse, maintaining privacy, protecting patient confidentiality, and allowing enough time to complete the assessment. Communication is the next step. During this step, the nurse introduces themselves to the patient. Using active listening and allowing the patient to tell their story is very important during this step. Use of technical terms should be avoided. Questioning should begin with open-ended questions. Examples include: “Tell me about your health problems” or “How does the affect you”...
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...Chapter 1 The Patient Interview Sneha Baxi Srivastava, PharmD, BCACP Learning Objectives • Explain the basic communication skills needed when performing a patient interview. • Describe the components of the patient interview. • Conduct a thorough medication history. • Compare and contrast the different patient interview approaches in various clinical settings. • Adapt the interview technique based on the needs of the patient. Key Terms • Active Listening • Rapport • Empathy • Open-Ended Questions • Leading Questions • Probing Questions • Nonverbal Communication • Chief Complaint • History of Present Illness • Pertinent Positive • Pertinent Negative • Past History • Medication History • Family History • Personal and Social History • Review of Systems • Physical Exam • QuEST/SCHOLAR-MAC Introduction The patient interview is the primary way of obtaining comprehensive information about the patient in order to provide effective patient-centered care, and the medication history component is the pharmacist’s expertise. A methodological approach is used to obtain information from the patient, usually starting with determining the patient’s chief complaint, also known as the reason for the healthcare visit, and then 2 Chapter 1 / The Patient Interview delving further into an exploration of the patient’s specific complaint and problem. A comprehensive patient interview includes inquiring about the patient’s...
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...Technologists Role in Quality Patient Care and Safety Keiser University Abstract I never really sat down and realized how important patient care really was going to be to my job. I always just thought of it as just taking pictures of the bones. Come to find out there really is a whole lot more to it than what I thought. Quality patient care is very important from the way that we communicate with the patient all the way to the time they go home and or are released from the hospital or care. There are several protocols and procedures that we are required to follow and abide by. These are just done to ensure that neither the patient nor we get hurt; and that everything is done in a safe manner. The patient’s life kind of still lies in your hands sometimes. Radiology Technologists Role in Quality Patient Care and Safety How would you feel if the Radiology Technologists that was taking care of you didn’t know what they were doing? I know that I wouldn’t feel comfortable and would probably ask to have someone else take care of me. Which as a patient we have that right; but there are roles and guidelines that the Radiology Technologists have the duty to follow as well. The American Society of Radiologic Technologists has made a Code of Ethics that should be followed. These Code of Ethics are put into place to make sure that the patient receives quality care, its...
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...textbook. Each medical record should be completed and contain two questions you would ask of the potential hires. The following suggestions will help you get started: • Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis. • For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history. • For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness. • For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam. • For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis. • For...
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...Focussed Assessment In the given case study patient has persistence vomiting for eight days and she took Antaacids to relieve the symptoms. She is dehydrated, and her lab results shows she has metabolic alkalosis. In focused assessment, detailed nursing assessment of particular body system(s) connected to the current problem is required. One or more body system may be involved.Nausea and vomiting can ocurr due to different reasons like food poisoning,chloecystitis or intestinal obstruction..For the patient with vomitting,intially the health care provider need to pay attention to signs of dehydration. Like assessing monitoring blood pressure and observing for hypotension, skin turgour and mucous membranes changes (McCance, Huether, Brashers, & Neal, 2014). General Assessment: Patient had dark circles under the eyes. She looked worn out. She was feeling anxious. Her energy level was very low. She was speaking very slowly. Abdominal Examination: Abdomen is soft to touch. Patient has some epigastric pain. Bowel sounds are decreased.No bloating or acidity. Signs of hypo-motility may indicate an increased risk for nausea and vomiting. Cardiovascular system: Patient is hypotensive with tachycardia. No heart regurgitation or murmur. Heart rhytm is regular. Patient is feeling tired and dizzy. Pulmonary system: Patient is in metabolic alkalosis. Respirations rate is low 12 breaths per minute. Patient is taking deep regular breaths. Lungs are clear to ausculation...
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...One of the main risk factors associated with individuals that have atrial fibrillation is stroke. While anticoagulants can help with this associated risk, not all patients with atrial fibrillations are at risk of developing a stroke. This can be an issue for some patients as taking anticoagulants can lead to other issues like bleeding. With that in mind, there is a scoring system in place called CHA2DS2-VASc, that help determine if a patient may require anticoagulant therapy. 1 This scoring system is broken down into seven risk factors that are assigned a specific score. These risk factors are then summed up to a possible maximum score of 9; higher scores suggest a higher risk of stroke. The seven risk factors are Congestive heart failure,...
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...Nursing Process Focus: Patients Receiving Phenelzine (Nardil) |Assessment |Potential Nursing Diagnoses | |Prior to administration: |Sorrow, Chronic related to | |Obtain complete medical history including allergies, neurological , |depressive state. | |cardiac, renal, biliary, and mental disorders including blood |Thought Processes, Disturbed related to | |studies: CBC, platelets and liver enzymes,. |effects of drug therapy | |Obtain patient’s drug history to determine possible drug interactions|Adjustment, Impaired related to inadequate | |and allergies |drug effectiveness. | |Obtain 24 hour dietary history to identify |Knowledge, Deficient, related to drug | |tyramine containing foods ingested |action and side effects. | |recently |Suicide, Risk for related to inadequate drug ...
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...improve health," adds Mather. "Mendocino Coast District Hospital is embracing the future of healthcare and taking the lead to create a healthy community. There are very few hospitals that have truly made it their mission to heal and not just treat the signs and symptoms of illness." A healing physical environment. This concept takes into consideration not only how we care for patients, but also how our staff engages with families as caregivers. We have learned that by creating a loving, compassionate, and aesthetically pleasing environment, we are able to help patients and families cope with stress and illness. Mercy Gilbert Medical Center promotes a quiet environment that supports healing for patients, in addition to providing a calmer, more stress free environment for staff and The second component of a healing hospital enables the staff at Mercy Gilbert Medical Center to work more efficiently while providing additional privacy and security for patients. Utilizing the most advanced technology available today also assists in providing a healing environment. The third and most critical component of a healing hospital is embracing a culture of Radical Loving Care, a philosophy championed by healthcare industry leader Erie Chapman. By embracing this \philosophy, Mercy Gilbert Medical Center has developed a strong culture of compassionate care, taking healthcare workers back to their roots and reminding them why they went into...
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... Genitourinary Care Plan Patient Initials: H.M Age: 60 years old Sex: Male Subjective Data: Client Complaints: Decreased Urinary flow, dysuria, nocturia, urinary frequency, low grade fever. HPI (History of Present Illness): This 60 year old Hispanic male presents at the clinic today with a chief complaint of urinary frequency, decreased urine flow, increased nocturia, slight terminal dysuria and low grade fever. The patient was experiencing these symptoms for the past two years, but they had increased a whole lot more during the last two weeks. Upon assessment, it is noted that the patient has a systolic murmur that is more audible at the right sternal border. Five years ago, patient was in the hospital with suspected angina. At the moment, the patient presented with a PSA level of 6.0. In the past patient did not seek medical advice or treatment for his symptoms which have worsening now and forced him to look for medical assistance. PMH (Past Medical History—include current medications, any known allergies, any history of surgery or hospitalizations): Patient has history of urinary frequency, decreased urine flow, nocturia and dysuria which he did not seek medical help for. Patient was hospitalized five years ago, where he was treated for chest wall syndrome. Patient is currently under treatment for high cholesterol and hypertension. No history of heart disease. No surgeries in the past. Allergies: He has no known...
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...a healthcare professional to improve their health. Therefore, I joined Mobile Clinic organization this semester where I could provide medication service to patients like blood pressure screening and taking medication history to support their health and well being. I learned that adverse drug events which are defined as injury due to a medication are very common. They affect approximately 10% of the patients during hospitalization and 15% of patients during the first few weeks after hospital discharge. Errors in the medication history that healthcare providers take from patients are an important contributor to adverse events. These errors account for up to 75% of all potentially harmful medication discrepancies in admission and discharge orders. Errors in the history can lead to patients receiving the wrong medications. Taking a good medication history is there for not just a regulatory requirement. It is important for improving medication safety during transitions of care. The goal of a good medication history is to obtain complete information on the patient’s regimen, including: name of each medication, formulation, dosage, route, and frequency. It is also important to distinguish between what patients are supposed to be on versus what they actually take....
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...(1/1): “heaviness on the chest, and shortness of breath” Symptom Analysis (History of present illness): 43 year old male presents today for evaluation with complains of chest heaviness and shortness of breath and Associated signs and symptom including nausea, and feeling of tiredness. The patient has been treated with similar symptoms before. Patient reports that he has had these symptoms for 2 days. Patient describes the heaviness on the chest as a feeling like someone is stepping on the chest. He describes the SOB as feeling out of air, and gasping for air when taking the stairs to his apartment, or doing daily chore at home. Patient reports of having to stop his daily activities and unable to do anything that he usually does. Patient reports of not getting any relief from his nebulizer. He denies having any pain. Past medical History: Patient’s problem list includes Dx of COPD in 2010 and CHF in 2007. Patient has no known medical allergies, or any allergies to food, denies any previous surgeries has previously been hospitalized for CHF and COPD. He reports receiving yearly flu shot; he also reports having not received Tetanus and Tdap immunizations. He is currently taking Lasix 20 mg daily for CHF and he is also taking albuterol Neb PRN for SOB SOCIAL HISTORY: Patient reports that he quit smoking 3 years ago; he had been a smoker for 15 years smoking an average of 7 cigarettes per day. Patient previously worked at a road construction company, he had been on this job...
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