Taking A Patient History : The Role Of The Nurse

2007, Pp.206-212). Working towards, and gaining knowledge of all skills, and the importance of communication has allowed me to strengthen my own understanding when communicating with others. As a student nurse, I need to understand the importance and reliance of my record keeping, to the continuity of care for patients. It is imperative that any nursing records I keep is complete, is accurate to prevent potential miscommunication and mistakes, and must be countersigned by a registered nurse. Notes should include the status of the patient and patient’s wishes, so that appropriate actions can be taken and in accordance with those wishes. Unless the patient lacks the mental capacity, then alternatively would act in the best interests of the patient according to: The Mental Capacity Act (2005). The patient’s notes should also emphasise the intervention outcome, I too need to be conscious of the language used within documents is clear, so others can understand it. Under the Data Protection Act (1998), I have a professional legal duty to keep all documents which I’m responsible for, confidential at all times. Documentation of clinical records, will help ensure that I am encouraging

Seeing information about a healthcare user in such terms makes me realise that some information is not necessarily in the public domain and therefore I have a privilege and responsibility to not only care for the patient but also for the knowledge about them that I am privy to. I realise that, although I have a duty to retain confidentiality, I may be placed in a position where the confidence has to also include other healthcare professionals and I need to involve the patient in such a situation (ibid).

For this assignment I will be writing a reflective account which will identify a significant episode of care in which I had been involved with, by identifying the pathophysiology and the disease process for the chosen patient; this will be presented by giving a brief outline of the psychosocial influences of the illness for the patient and others who may have been involved with the care. I will also reflect upon this episode by using a reflective model and examining the nursing process, using a holistic perspective throughout the reflective framework. Maintaining confidentiality is a key element, outlined in the Nursing Midwifery Council the Code (2008).

Every patient that comes in seeking medical attention, has had a health history assessment conducted on them. Such an assessment provides health care workers such nurses, with vital information about the patient’s overall well-being. It can also be viewed as a guide in directing the nurse, in provided the most beneficial and utmost plan of care. The purpose of this paper is to exemplify a conducted health history assessment on a patient represented by the initials L.H.; Which focuses on subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings.

3. Q) What type of information is gathered when obtaining the Social History of the patient? Why is this important?

A heritage assessment in nursing is a vital tool to learning about a patient. By finding out about the patient’s family and friends we can learn about their support system. If we learn how close to a culture our patient is this will give us an idea of how true they hold their beliefs or if they have went mainstream with the American culture. Doing interviews with different cultures gives us a look into their personal beliefs and can help nurses to provide better care and teaching to these patients. Some patients we will learn were born in

Heritage is a cultural aspect or tradition that has been passed down through generations (Heritage Assessment, 2016). Why would the health professional need to know about a patient’s cultural background? How would this affect the care provided? Health care is specific to the individual needs of a patient, and no two are alike. Nurses should conduct an assessment of the patients’ cultural beliefs, values, religious beliefs, and practices. It is important to learn the meaning of the illness from the patients point of view. Data collected from the cultural assessment will help the patient and nurse to develop a mutual and culturally acceptable plan

Patient stories bring healthcare experiences to life highlighting if they are positive or negative. They encourage the NHS to focus on the person and view then as a statistic. Stories can be told from the point of view of the patient therefore the focus is solely on the individual and not the condition. Stories are made up of a complex network of events from admission to discharge.Stories can be sourced from patients and families, members of staff and care workers. Everyone’s experience of the healthcare experience is valuable. Patient experiences are used to improve healthcare, however and individual story is not a representation of all patient experiences. Stories help us to see things from the point of view of a

The NMC Code (2008) charges nurses to protect confidential information, and to only use it for the purposes given – for their treatment. Therefore all patients and events mentioned in this essay are inspired by real patients and events, but names, locations, dates and other details have been altered or obscured to make identification impossible. Following the introduction of the knowledge and skills framework (DH 2004a) and emphasis on quality of health care and patient centred, interprofessional, health and social care (DH 2000; Leathard 2003; Thompson et al. 2002) health care professionals and students will need to be able to

A. Identify appropriate history questions to be asked of the patient, nursing staff, or family in order to discriminate critical characteristics or attributes about the presenting problem.

Being a patient is stressful as it is, and as nurses we should elevate them of this stress and empower them to look pass their illness. In the process of empowerment, information that is shared by the patient must remain confidential unless if we must report it by law. As nurses we must educate patients and their support system on diagnosis and treatment types. Keeping in mind of individual from different cultures that have different treatment methods than the Western ways, as nurses we must be culturally competent. I have educated myself on different cultures, and I have the belief that culture plays a significant role in the treatment of illness. Continuously reeducating myself on different cultures is vital because new things are learned about culture every day. Rather than believing in stereotypes, nurses must take the time to know the patient. Building a relationship with the patient will lead to effective treatment plans and the patient

The aim of this essay is to demonstrate the assessment process of a patient using the Roper Logan and Tierney (RLT) model of nursing framework and to show how the nursing process works alongside this model. This will be shown by a holistic history of the patient being shown, followed by how the RLT model is applicable to this patient. This is then followed by one nursing intervention being discussed showing how the nursing process is applied to patient care. The patient will be referred to as Mr Frederick Valentine to protect the patient’s anonymity as stated in the Nursing and Midwifery Council Code of Conduct (2008) guidelines.

Using this example, we clearly see that the nurse asks the patient a direct and clear question so as to get information and in turn she gets a response. It is suggested that this is a good example of questioning and probing and it is recommended to be used again in future. To provide the most effective care possible, nurses must begin with clear and appropriate verbal skills such as being honest, being concise and keeping emotions out of the conversation (Apler, 2006).

Permission was consented from the patient to use their condition for this essay; the information was accumulated from their admission, assessment and plan of care. The patient authorized usage of information relating to their period of hospitalisation in agreement that any personal information would not be used. This essay will address this matter in accordance with the Nursing and Midwifery Council (NMC) confidentiality guidelines set out in the Code of Professional Conduct (NMC, 2004). The pseudonym “David” will be used for this reason throughout this essay.

Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, & Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met.