crazy nurse28. . .the history is only one part of your interview process with the patient during your data gathering process. normally, the history is considered subjective information because it is being supplied by the patient. in writing it up, it needs to be kept separate from the objective information you will also be presenting. some of this data can come from the patient's past medical history that you might find in their chart. you would find it in the physician's history and physical or an emergency room report. physicians look at five major components of a patient's medical history and nurses can do this as well. these are the five components:
- chief complaint - this is where the patients tell you, in their own words, why they came into the facility for medical help. if the patient happens to use any medical terms, have them define those terms for you to make sure you understand what the patient's perception and meaning of those terms are.
- history of present illness - this is what has just changed in the last days or weeks in the patient's level of health that has led them to seek out medical attention at this time. it should answer the questions of what, when, how, where, which, who and why in relation to their chief complaint. basically, it will be the story of how they came to the medical situation they find theirself in.
- past medical history - this is the assessment of the patient's health status before this current illness. any of all of the following are included: past illnesses (don't forget childhood illnesses), injuries or major accidents, hospitalizations (for both medical and psychiatric illnesses), surgery, allergies (food, drugs or environmental), immunizations, any substance abuse (cigarettes, alcohol, recreational drugs), diet (it is helpful to ask the patient to describe what they ate for their meals the day before), sleep patterns and current medication (don't forget over-the-counter medications and any contraception). if your patient is a female of child-bearing years you need to get obstetrical and gynecological information
- family history - ask about the age and health of members of immediate family and include the age and cause of death of those who may be deceased. place of birth may often be important. you are looking for clues about possible genetic and environmental diseases that might have implications for your patient
- psychosocial history - this includes information about education, life experiences and personal relationships in the patient's life. their lifestyle, who they live with, religious beliefs, employment and the person's outlook about their future are part of this section of the history
the next part of history taking is called the review of systems
. it your chance to question the patient about any very specific symptoms they may have had in the past or have currently that may have been overlooked during the questioning about their past history. it is organized by body systems, usually easiest by going from head to toe. there is not enough space here to list everything you should ask, so i leave it to you to research this out unless your instructor has already given you this information. here is a list of the head to toe body system sequence i would use:
- mouth and throat
- male genitalia
- female genitalia
to answer the question you posed in your post. . .do i only get the history of the patient or do i also have to get the normal value and make comparisons already and start with the nursing diagnosis?
. .what you will do is interview your patient to obtain their input of the information about their medical history that i've outlined for you above. if your instructor is also directing you to get lab results, x-ray results and look at things like procedure reports in the patient's chart, you will do that as well. i have always preferred to get information from the chart before interviewing any patient. getting information from the chart, however, is not part of the interview process. it is part of your data collection process. chart data is rightfully history items, but when you write all this information down to hand in to your instructor, you should not mix them up with the information you are getting from the patient from your interview. you need to keep your interview information separate so anyone reading it is aware that it was obtained from a patient interview. lab/test results are going to be included with the physical examination data you will also be collecting later because it is objective information. you can put an initial statement about the first labwork obtained upon admission into the facility into the "history of present illness" section of the history this way, if you like, but it is not necessary: "the patient presented to the hospital with an inital cbc of ... and electrolytes of ..."
you don't start making comparisons of the empirical test data or start grouping the abnormal findings from your data collection activities just yet. one very large component of your data collection process is still missing. that is your nursing physical examination and assessment of the patient. you need to do things like examine the patient's skin, listen to their heart and lungs, palpate their abdomen and check for edema as well as their ability to ambulate and many other things. once completed, that information is added to all the other data you've collected. the empirical test data belong with the physical assessment data. now, you'll have completed your initial data collection process, the first step in planning nursing care. that's already a lot of work, isn't it?
to get back to your question, now
you can start making comparisons of the empirical test data and start grouping the abnormal findings from your data collection activities and assembling them into the defining characteristics (symptoms) that make up the nursing diagnoses that you will assign to the patient. that, then, is the second step in the nursing process, planning your nursing care.
hope i have explained this process for you so that you can understand what you are supposed to do. the nursing process has a very logical sequence to it. it is a little mysterious and perhaps confusing at first, but after you go through it a few times it gets easier for you.