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 patients 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 Johnsons 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 quiet environment that is free of interruptions? A private 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 patient can stay focused on the history. Make sure that the patient is comfortable and that the room is warm and well lit. If the patient uses 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 takingit sends the message to your patient that the health history form is more important than he or she is. Also, if you are 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 patients permission before starting. Position the equipments as unobtrusively as possible so that it does not distract you or your patient. Your approach to your patient depends on his or her cultural background, age, and developmental level. Ask yourself, Are there any cultural considerations that might influence our interaction? What approach is best, considering my patients age?

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 Medical History Physicians diagnose and treat illness. Nursing History Nurses diagnose and treat the patients 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 any preexisting medical problems that might Nursing History It ALSO focuses on the cause of the injury, but the purpose is to determine Mary Johnsons response to the injury. clues about the impact of the

make her a poor surgical risk Develop a treatment plan for the fracture.

injury on her ability to perform her everyday activities help you identify strengths she has that can be incorporated into her plan of care identify supports and begin your discharge plan develop Care Plan not only in her perioperative 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 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 patients 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 into consideration of ethnic or cultural background ,age, and developmental level Use open-ended questions to elicit patients perspective Attend to acute problems, such as pain, before going to detailed history Quality is more important than quantity of information