NR 509-Importance of taking a Comprehensive Health History.

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Running head: Comprehensive Health History 1 Importance of taking a Comprehensive Health History Lisa Ulrich RN Chamberlain School of Nursing This study source was downloaded by 100000831988016 fr... om CourseHero.com on 05-01-2022 09:05:40 GMT -05:00 https://www.coursehero.com/file/66227480/Importance-of-taking-a-Comprehensive-Health-Historydocx/ COMPREHENSIVE HEALTH HISTORY 2 Importance of taking a Comprehensive Health History The basis of all foundation of health care is the act of being able to gather information which is considered the basis or foundation of health. (Phillips, A., Loftin, C., Shepherd, S, 2017). The goal of taking a comprehensive history and review ROS system on the first encounter with the patient is the part of the first step in the nursing process, (Phillips, A., Loftin, C., Shepherd, S, 2017). NP have the greatest ability in building the gateway to an effective nurse– patient relationship that will make patients feel at ease, supported, and empowered. This is important part of building relationships with outpatient. Listening is the first important tool in taking a comprehensive health history. Listening simply is just actively listening. Active listening involves fully comprehending what a patient is communicating through both verbal and nonverbal cues (such as body language), as well as the patient’s emotional state, (Phillips, A., Loftin, C., Shepherd, S, 2017). Complete concentration is essential during a nursing assessment. Listen carefully, using verbal and nonverbal prompts to encourage the patient to expand on his or her symptoms and the circumstances surrounding them. Empathy another key factor when doing a comprehensive assessment. Empathy demonstrates that you understand and care about what a patient is experiencing and helps establish a trusting nurse–patient relationship. Empathic responses during a health history assessment interview can be both verbal (“I understand”) and nonverbal (such as offering a tissue if the patient is crying). Beyond being empathic, be sure to validate patients’ feelings to help reassure them that their emotions are natural and reasonable. In addition, communicating their problems are understood, and will be addressed. Another technique used is guided questioning, adaptive and questioning. This helps to encourage a patient to fully communicate without interrupting the flow of his or her narrative. Starting with general questions, making them more specific as you move through the interview. Health assessments in nursing require questioning that that are responded more than just a yes/no answers. A series of questions, asked one at a time, often helps patients open, as does offering multiple choices for answers. Request additional information when necessary by asking the patient to clarify their statements. Repeating his or her statements (a technique called echoing) is also helpful, Being in tune with the patient nonverbal communication, such as eye contact, facial expression is another importance aspect of that helps NP to understand more fully with using their own This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 09:05:40 GMT -05:00 https://www.coursehero.com/file/66227480/Importance-of-taking-a-Comprehensive-Health-Historydocx/ COMPREHENSIVE HEALTH HISTORY 3 nonverbal communication themselves. Mirroring a patient position or using therapeutic physical, maybe placing hand on patients’ arm can further the health assessment as well as creating a relationship. Another essential element of a nursing health assessment is expressing to the patient that you are committed to forging a continuing partnership dedicated to his or her wellness. Another tool for the NP is to summarize what the patient has said. This demonstrates that you’ve been listening and can fill in holes in the patient’s story. Empowering our patient is essential with the idea that their participation in the process and working closely with their medical team can make a positive impact with the patient and their outcomes. Expected normal subjective findings week 1 Constitutional- Patient reports unable to bare weight on right foot Skin- Patient subjected complaints of right foot pain with pus drainage. Patient reports she had scraped her foot approximately 1 month ago. Patient also wants to establish a primary care provider. HEENT- Patient reports normal eyes, ears, nose and throat. Neuro- Denies findings, Respiratory, patient denies complaints. Reports history of Asthma. Cardiovascular -Patient denies complaints, Neuro- patient denies complaints, MSK, Patient reports no subjective findings, GI no complaints, GU, patient denies complaints, Psych, denies complaints and Gyno, patient reports she has not had a Gyno checkup in years Patient chief complaints were right foot pain. Objective findings consisted of diabetic foot ulcer to right foot heal with drainage. Skin Constitutional heent respiratory neuro This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 09:05:40 GMT -05:00 https://www.coursehero.com/file/66227480/Importance-of-taking-a-Comprehensive-Health-Historydocx/ COMPREHENSIVE HEALTH HISTORY 4 MSK GI GU psych Gyno o Provide an overview of the objective data and expected normal physical examination findings for this body system. NOTE: If writing this assignment for Week 1, provide the expected normal subjective findings for each body systems on the ROS. o Explain special physical assessment examination techniques or procedures specific to assessing this body system. NOTE: If writing the assignment for Week 1, explain advanced interview techniques. o Analyze and discuss how you might adapt your physical assessment skills or interviewing techniques to accommodate each of the following specific populations:  Infant/pediatric  Pregnancy  Geriatric Assessment is considered the bas [Show More]

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