Which questions would the nurse ask a patient when obtaining the patients medication history?
Chapter 2: Obtaining a Health HistoryIntroductionThe collection of a health history from a patient - that is, subjective data which focuses on the patient's symptoms - is the first step in health observation and assessment, and is a fundamental skill for nurses working in all clinical areas. This chapter introduces the knowledge and skills required by nurses to collect a comprehensive health history from a patient. It begins with an explanation of the place of health history in the health observation and assessment process, a description of the different types of health histories and their uses, and a detailed overview of the components of a comprehensive health history. This chapter goes on to explain the importance of therapeutic communication and rapport in the health history interview, and the use of questioning, interpersonal skills and other communication techniques to facilitate data collection. Finally, this chapter considers a variety of barriers and challenges to effective communication in the health history interview, and how nurses can respond effectively to these. Show
Learning objectives for this chapterBy the end of this chapter, we would like you:
Get Help With Your Nursing Essay If you need assistance with writing your essay, our professional nursing essay writing service is here to help! Find out more As you saw in the previous chapter of this module, health observation and assessment involves three concurrent steps:
The first of these steps, and the focus of this chapter, is the health history. This involves collecting subjective data - that is, data about a patient's symptoms (i.e. what the patient experiences). A variety of other important information is also collected during the interview - including, for example, information about a person's health-related values, beliefs and attitudes, their current health-related practices, the socioeconomic, cultural and other factors impacting on their health, and their willingness and capacity to make health-related changes, etc. Data is collected via an interview with the patient and / or significant others. Data collected at this stage may be primary (i.e. obtained from the patient themselves) or secondary (i.e. obtained from another person, such as the patient's family member or carer, etc.). In acute situations, the patient's health history may be communicated by another health care provider - for example, an emergency paramedic. Health history is obtained through an interview between a nurse, the patient and significant others (where appropriate). The nurse's role in the interview process is to: (1) facilitate discussion to collect health-related data, and (2) record this data. Data collected during a health history interview informs both the subsequent physical examination of the patient, and also the health care which is provided to that patient. In many clinical settings, patients are asked to complete a questionnaire as part of the process of collecting their health history. Health history questionnaires typically consist of a series of simple yes / no questions, often related to the specific symptoms and risk factors associated with common disease (e.g. cardiovascular disease, respiratory disease, diabetes, etc.). It is important for nurses to realise that health history questionnaires do not replace or preclude the need for the health history interview. Although these questionnaires can be useful tools for collecting data related to a person's health history, and can prompt a patient to think deeply about their past medical problems and symptoms, they only collect superficial information which should then be further investigated by a nurse in a conversation with a patient. Types of health historiesIt is important for nurses to note that there are a number of different types of health histories which may be collected from a patient:
The type of health history collected from a patient depends on: (1) the context in which the patient has presented, and (2) the patient's health care issues and needs. This module will focus on teaching the knowledge and skills required to collect a comprehensive health history from a patient, as it is this knowledge and these skills which also underpin the collection of a rapid or focused health assessment. Components of a health historyA health history interview typically consists of three distinct sections: (1) introduction, (2) discussion, and (3) summary. Each of these sections is described following:
All health history interviews begin with the nurse introducing themselves to the patient (and others present in the interview, if relevant), and explaining their role in the provision of the patient's health care. Adult patients should be addressed by their title and surname, until they inform the nurse of their preferred name and provide the nurse with permission to use it. It is usually acceptable, and preferable, to address adolescents and children by their first name. Nurses explain why the interview is being conducted, and also the processes involved. The aim of this explanation is to prepare the patient and to enhance their comfort in sharing health-related information. The next section of the interview, the discussion section, is where the nurse focuses on facilitating discussion with the patient to collect health-related data. The nurse uses a range of questioning and other communication techniques - discussed in detail in the following section of this chapter - to collect the information required to inform the physical examination and the subsequent provision of the patient's health care. This discussion is patient-centred - that is, it focuses on the person and their unique issues and needs. Patients are encouraged to share their perceptions and experiences in their own words, without interruption, judgement or interpretation from others (including the nurse). The nurse focuses on collecting the following information:
It is important to highlight that many health care organisations have standardised templates which nurses can use to guide their collection of this data during a health history interview. Nurses must ensure they are familiar with the location of these templates, how to access them, and how they are expected to apply them in practice. Practicing using these templates (e.g. on family, friends, colleagues, supervisors, etc.) can be useful in helping a nurse to gain confidence and competence. The final section of the interview is the summary section. Nurses should summarise the key data collected during the interview - that is, the main points that the patient has communicated. The patient should be encouraged to clarify any errors or inaccuracies in the information the nurse has collected; often, errors occur when a nurse incorrectly interprets the information provided by a patient (note that barriers to communication when collecting a health history will be described in detail in a later section of this unit). The nurse should also explain to the patient how the information gathered during the health history interview will be used to inform the healthcare provided to them. Although it is brief, the summary section of the health history is important because it provides a patient with a sense of validation that the nurse understands, and will respond appropriately to, their health issues and needs. Get Help With Your Nursing Essay If you need assistance with writing your essay, our professional nursing essay writing service is here to help! Find out more Therapeutic communication and rapportThe nurse's effective use of communication techniques, underpinned by therapeutic communication practices, is the single most important factor in the success of a health history interview. Therapeutic communication focuses on developing rapport with a patient - that is, a trusting relationship with a patient which facilitates their comfort in sharing personal information. There are a number of important factors which impact on the development of rapport in the health care setting:
Privacy is crucial in facilitating a patient's ease in discussing personal information. Patients may be unwilling to share sensitive information in an open and honest way if they are fearful of being overheard by others (including their family / friends, members of the public and / or health care providers). Ideally, health history interviews are conducted in private examination rooms; however, depending on the clinical context in which a nurse works, this may not always be possible, and a nurse may have to instead draw curtains around a cubicle or pull chairs to a quieter part of a larger treatment room, etc. The nurse should carefully consider whether the presence of the patient's family or significant others is appropriate during the interview. If the nurse judges that the presence of these people may impede the patient sharing sensitive information, these people should be invited to wait in a visitors' room or other location whilst the interview and physical examination are being conducted. The location in which an interview is conducted should be quiet and free from distractions. Interruptions should be avoided to the greatest possible extent - for example, a nurse should avoid an area which must be frequently accessed by other staff or an area which is adjacent to a thoroughfare. Any unnecessary equipment in the interview space - including telephones and pagers, etc. - should be turned off, and removed if possible. Nurses may consider placing an 'Interview / Examination in Progress' sign on the door or curtain to discourage interruptions. To facilitate a patient's ease in discussing personal information, they must also be physically comfortable throughout the interview. Wherever possible, the nurse should allow patients to remain in their own clothes for the interview (and change into a hospital gown immediately prior to the physical examination). The nurse should sit at a distance and angle from the patient which respects their personal space, whilst still promoting the flow of conversation. When planning for the patient's comfort, the nurse should also consider the seating provided, the temperature and lighting of the room, and the patient's access to water and toilets (if required).
Questioning, interpersonal skills and other communication techniquesQuestioning is a key communication skill used by nurses during the health history interview. Questioning occurs in two equally-important parts: (1) asking the patient for information, and (2) listening carefully to the patient's response. There are two key types of questions a nurse may ask during a health history interview:
Example
Open-ended questions are useful when a nurse wishes to collect general data about a patient's symptoms, their health-related values, beliefs and attitudes, their current health-related practices, the socioeconomic, cultural and other factors impacting on their health, and their willingness and capacity to make health-related changes. However, a nurse should be careful to ask open-ended questions in a way which facilitates the collection of the data required. For example, a question such as: "Tell me a little about yourself" is too broad for a health history interview; it will likely result in the patient providing the nurse with information which is irrelevant to their health care.
Example
Closed-ended questions are useful in collecting information about a specific topic, to clarify information gathered during open-ended questioning and in urgent situations where information is required rapidly. However, a nurse should be careful to avoid drawing inaccurate conclusions from the short answers a patient provides to closed-ended questions. In addition to questioning, there are a variety of other communication strategies a nurse should use when collecting data from a patient during a health history interview. These skills include:
When communicating with patients, including when conducting health history interviews, it is important for nurses to realise that people are not always direct in saying what they mean. Nurses must be conscious of picking up on 'cues', or subtle hints which suggest the patient may have an underlying concern they are finding difficult to discuss. There are a number of cues seen commonly in health care settings:
If a nurse identifies one of these cues, they should question the patient in a respectful and sensitive manner to further explore the topic - if it is appropriate and relevant to do so. There are also a number of general strategies nurses should use when questioning patients during a health history interview:
Barriers to effective communicationIt is important for nurses to recognise that there are a variety of barriers that diminish the quality of the data collected during a health history interview - for example, by interrupting the flow of the interview or impairing the rapport between the nurse and the patient, etc. The key barriers - which nurses conducting health history interviews must take care to avoid - are described in the following section:
It is important to note that there are a variety of other challenges a nurse may encounter when completing a health history interview. These challenges, and how a nurse may effectively manage them, are described following:
Get Help With Your Nursing Essay If you need assistance with writing your essay, our professional nursing essay writing service is here to help! Find out more ConclusionAs you have seen in this chapter, the collection of a health history from a patient - that is, subjective data, which focuses on the patient's symptoms - is the first step in health observation and assessment, and a fundamental skill for nurses working in all clinical areas. This chapter has introduced the knowledge and skills required by nurses to collect a comprehensive health history from a patient. It began with an explanation of the place of health history in the health observation and assessment process, a description of the different types of health histories and their uses, and a detailed overview of the components of a comprehensive health history. This chapter went on to explain the importance of therapeutic communication and rapport in the health history interview, and the use of questioning, interpersonal skills and other communication techniques to facilitate data collection. Finally, this chapter considered the variety of barriers and challenges to effective communication in the health history interview, and how nurses can respond effectively to these. In completing this chapter, you have equipped yourself with the knowledge and skills necessary to collect a comprehensive health history from a patient. ReflectionNow we have reached the end of this chapter, you should be able:
Reference listCox, C. (2009). Physical Assessment for Nurses (2nd edn.). West Sussex, UK: Blackwell Publishing, Ltd. Fawcett, T. & Rhynas, S. (2012). Taking a patient history: The role of the nurse. Nursing Standard, 26(24), 41-46. Jensen, S. (2014). Nursing Health Assessment: A Best Practice Approach. London, UK: Wolters Kluwer Publishing. Kaufman, G. (2008). Patient assessment: Effective consultation and history taking. Nursing Standard, 23(4), 50-56. Kourkouta, L. & Papathanasiou, I.V. (2014). Communication in nursing practice. Materia Sociomedica, 26(1), 65-67. Royal College of Nursing. (2016). Action on Communication. Retrieved from: https://www2.rcn.org.uk/development/practice/patient_safety/human_factors_communication/action_on_communication Wilson, S.F. & Giddens, J.F. (2005). Health Assessment for Nursing Practice (4th edn.). St Louis, MI: Mosby Elsevier. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. Reference Copied to Clipboard. What questions would be asked for patient history?The Rest of the History. Past Medical History: Start by asking the patient if they have any medical problems. ... . Past Surgical History: Were they ever operated on, even as a child? ... . Medications: Do they take any prescription medicines? ... . Allergies/Reactions: Have they experienced any adverse reactions to medications?. What should be included when obtaining a complete medication history?A good medication history should encompass all currently and recently prescribed drugs, previous adverse drug reactions including hypersensitivity reactions, any over-the counter medications, including herbal or alternative medicines, and adherence to therapy.
What is the nurse's responsibility when obtaining a medication history?Nurses considered themselves to be second only to physicians in medication reconciliation since they: obtain an accurate medication history on admission, verify and reconcile discrepancies between the medication history list, those ordered on admission and at transition, and send the discharge medication list to the ...
What questions does a nurse ask a patient?The Most Common Questions. When can I see my doctor? Nurses may be trusted and respected, but most patients view their doctor as the authority for clinical answers.. When can I eat? ... . Can I have something for pain? ... . When can my family see me? ... . When can I go home? ... . Will it hurt? ... . What are my restrictions?. |