Taking a Patient History: The Role of a Nurse

Taking a Patient History: The Role of a Nurse

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Institution

Taking a Patient History: The Role of a Nurse

Introduction

Tonks Fawcett and Sarah Rhynas wrote the article Taking a Patient History: The Role of the Nurse. The article was accepted in 2011 and it was published in the Nursing Standard Journal in 2012.

Summary of the Article

The authors write about the importance of taking a patients history and they focus on the role of the nurses. In modern times, the roles and responsibilities of nurses have increased significantly. The authors detail the benefits of knowing how to take accurate descriptions of the patients’ history, noting that it is the main component of the assessment. Nurses should record the patients’ experiences as well as the signs and symptoms of the disease. They should do this using information from the patients and their family members or carers, and they should record the information they observe as well. This is essential in person centered care and it enables the nurses to give the patients individualized attention. The authors highlight the challenges that nurses may encounter when taking the patients history. They note that nurses not experienced in the job will have a difficult time. They do not have enough time to practice the skills they require, especially in clinical settings.

The authors observe that some nurses will have a hard time starting conversations with the patients and this can frustrate the entire process of history taking. They highlight the importance of having student mentors who act as role models. They also note that peer assisted learning is essential, as it helps the novice practitioners to share experiences and learn from each other. The authors have used literature review extensively. They have documented records from other sources that focus on the same issues. For instance, they have used this approach when writing about the guidelines that nurses should follow when taking the patients’ history and the elements that should be covered during consultation. Nurses deal with the patients more directly and they tend to spend most of the time with them. Because of this, they develop a relationship with them and this makes it easier for the nurses to obtain the medical history that they might need. Patients are able to reveal more information in an environment of trust.

Evaluation of the Article

I found the article interesting because of the perspectives it offered. Mostly, it deviated from the norm by engaging the reader. For instance, the time out sessions are intended to make the reader an active participant. They contain different tasks that make readers think about what they have learnt and how they can apply the lessons in different situations. They also contain details on where one can get more information concerning the different topics explored. The authors have done a good job in highlighting the necessity of history taking. In deed, after reading the article, one gets the feeling that it is one of the most important components of nursing. Their decision to highlight the various sources where the nurses can get the information they need is also commendable.

Nurses should not just rely on what the patients tell them, but they should be keen on making their own observations. Moreover, they should also consult the family members who take care of the patients daily. However, the authors should have highlighted the importance of engaging other sources of information as well. For instance, some people do not have family members but they do have other people who take care of them. In addition, I felt that the authors should have included more information concerning the challenges that nurses face when trying to take a patients history. For instance, they should have highlighted the challenges that the nurses experience when dealing with patients with different forms of disabilities. When describing the skills that the nurses require, the authors should have included the importance of observing non-verbal cues from the body language. This will enable the nurses to have more details concerning the patient (Smeltzer et al., 2010). For instance, nurses will be in a position to tell when a patient does not want to reveal some information.

More research should be undertaken on the issue, as it is necessary to have more information. For instance, patients tend to develop certain beliefs because of the experiences they have once they become sick. They have their own interpretations of the symptoms and some of them even attempt to make their own diagnosis even before consulting a physician. It would be interesting to find out if these beliefs contribute to defining the symptoms more clearly, as well as the strategies that nurses can use when making their own observations when taking the patients history. Moreover, extending the research on the topic would provide more information concerning the skills that nurses require and the strategies they can use to get more information from the clients. It would help to know how to counter the challenges that the nurses face when taking the patients history.

The authors were not concerned with explaining the process of history taking, although they did offer a few guidelines. Instead, they concentrated more on its importance and on the measures that nurses can take to ensure that they get the information they require. The health assessment strategy is indeed beneficial and it would benefit all health practices. It would lead to better diagnosis and prognosis and this would help to improve the health outcome of the society. Taking a patients history enables the nurse to understand the patient better and this leads to better care. Different factors affect the patients’ health and concentrating on the observable symptoms alone will not help to improve the situation. Nurses need to understand the nature of the patients’ psychology, physiology and psychosocial information. This includes understanding the family relations as well as cultural practices and beliefs. This knowledge will help the nurse to understand the patient in a better way. The nurse will be in a better position to know how the patient perceives his or her health status.

Conclusion

The authors highlight the benefits of taking a patients history. They note that nurses require different sources of information and they should not just depend on what the patients tell them. Patients tend to develop certain beliefs concerning their symptoms and depending on the information they give may not help the nurses much. However, if the nurses combine the information they receive from the patients with other details from their caregivers and the symptoms they observe, then they will be better placed to make informed decisions and take care of the patients better. Proper assessment is important for the patient. It ensures that the patients receive the proper diagnosis and that treatment efforts are successful. In addition, it ensures savings on costs and high quality care is guaranteed. Patients who receive good assessment and treatments do not have to keep on visiting their physicians.

References:

Cox, C. (2009). Physical assessment for nurses. Hoboken, NJ: John Wiley & Sons

Fawcett, T., & Rhynas, S. (2012). Taking a patient history: The role of the nurse. Nursing Standard, 26(24), 41-46

Smeltzer, O. S., Bare, G. B., Hinkle, L. J., & Cheever, H. K. (2010). Brunner & Suddarth’s textbook on medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins