WESTERN MINDANAO STATE UNIVERSITY COLLEGE OF NURSING Master in Nursing Program
Reporter Professor Topic Scene
: Maynard K. Baird, R.N : Sarah S. Taupan, RN, MN, DPA : Medical History Vs Nursing History & Setting the
Medical History versus Nursing History
The areas addressed and the questions asked during a medical health history re very similar to those in a nursing health history. However, some important differences exist. These differences are defined by the focus and scope of medical versus nursing practice. Although the history questions are similar, the underlying rationale differs. Remember: physicians diagnose and treat illness. Nurses diagnose and treat the patient’s response to a health problem. E.g., Mary Johnson, an 81-year-old woman, is admitted to the hospital with a fractured right hip Medical History: it would identify what caused the fracture in order to determine the extent of injury. The history would also try to identify any preexisting medical problems that might make her a poor surgical risk. The physician will use the data that he or she obtains to develop a treatment plan for the fracture. Nursing History: Although it focuses on the cause of the injury, the purpose is to determine Mary Johnson’s response to the injury. Or what effect it has on her. You will consider every aspect of her health and life. Your history will provide clues about the impact of the injury on her ability to perform her everyday activities and help you identify strengths she has that can be incorporated into her plan of care. You will also identify supports and begin your discharge plan. Then you will also use the data to develop a care plan with Mary Johnson that includes not only her perioperative phase but also her discharge rehabilitative planning.
Setting the Scene
Before beginning assessment, look at your surroundings. Do you have a quie quiett envi enviro ronm nmen entt that that is free free of inte interr rrup upti tion ons? s? A priv privat ate e room room is preferred, but if one is not available, provides privacy by using curtains or screens. Prevent interruptions and distractions so that both you and your pati patien entt can can stay stay focu focuse sed d on the the hist histor ory. y. Make Make sure sure that that the the pati patien entt is comf comfor orta tabl ble e and and that that the the room room is warm warm and and well well lit. lit. If the the patie patient nt us uses es assistant devices, such as glasses or a hearing aid, be sure that she or he uses them during the assessment to avoid any misperceptions. Before you begin asking questions, tell your patient what you will be doing and why. Inform him or her if you will be taking notes, and reassure the patient that what he or she says will be confidential. However, avoid excessive note taking—it sends the message to your patient that the health hist histor ory y form form is more more impo import rtan antt than than he or sh she e is. is. Also Also,, if you you are are too too preoccupied with writing and continually break eye contact, you may miss valuable nonverbal messages. Excessive note taking may also inhibit your patients’ responses, especially when discussing personal and sensitive issues such as sexuality or drug or alcohol use. Be sure to work at the same level as your patient. Sit across or next to her or him. Avoid anything that may break the flow of the interview. If the interview is being recorded or videotaped, be sure to get your patient’s permis permissio sion n befor before e starti starting. ng. Positi Position on the equipm equipment ents s as unobtr unobtrusi usivel vely y as possible so that it does not distract you or your patient. You Yourr appr pproac oach to your our pati patien entt depe depend nds s on his his or her her cultu ulturral backgr backgroun ound, d, age, age, and develo developme pmenta ntall level level.. Ask yourse yourself, lf, “Are “Are there there any cult cultur ural al consi conside dera rati tion ons s that that migh mightt infl influe uenc nce e our our inte intera ract ctio ion?” n?” “Wha “Whatt approach is best, considering my patients age?”
WESTERN MINDANAO STATE UNIVERSITY COLLEGE OF NURSING Master in Nursing Program
: Maynard K. Baird, R.N RN,MN,DPA : Sarah S. Taupan, RN,MN,DPA : Medical History Vs Nursing History & Setting the
Reporter Professor Topic Scene
Medical History versus Nursing History
Medical History
Physicians diagnose and treat illness.
Nursing History
Nurses diagnose and treat the patient’s the patient’s response to a health problem.
E.g., Mary Johnson, an 81-year-old woman, is admitted to the hospital with a fractured right hip
Medical History
identify what caused the fracture to determine the extent of injury identify a ny preexisting medi medica call prob proble lems ms that that migh mightt
Nursing History
It ALSO focuses on the cause of the injury, but the purpose is to determine Mary Johnson son’s response to the injury. clues about the impact of the
make her a poor surgical risk Deve Develo lop p a trea treatm tmen entt plan plan for for the fracture.
injury on her ability to perform her everyday activities help you identify strengths she has has that that can can be inco incorp rpor orat ated ed into her plan of care iden identi tify fy su supp ppor orts ts and and begi begin n your discharge plan develo develop p Care Care Plan Plan not only in her perioperati ative but also Rehabilitative
Setting the Scene
ENVIRONMENT:
Quiet Environment free from interruptions or distractions and provide privacy (private room is preferred) Patient is comfortable Room is warm and well lit Let patient use assistant devices (i.e., eye glasses, hearing aid, etc. ) if needed to to avoid misperception during assessment
ASKING Questions:
Rationale for asking question/ assessment Tell patient the time frame of the interview/assessment Inform patient if you are to document (obtain consent if needed) and assure confidentiality Start with the patient’s perceived problem Avoid excessive note taking – sends message to patient that health history is more important than he/she. Maintain eye contact and observe for nonverbal messages Work at the same level of your patient Take Take into into consid considera eratio tion n of ethnic ethnic or cultur cultural al backgr backgroun ound d ,age, ,age, and developmental level Use open-ended questions to elicit patients perspective Atte At tend nd to acut acute e prob proble lems ms,, su such ch as pain pain,, befo before re goin going g to deta detail iled ed history Quality is more important than quantity of information
