7.3: Data Collection II
The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family, environmental, psychosocial, and spiritual history.
The nurse collects a nursing history by interviewing the patient. A nursing interview is structured communication and is an effective way of gathering data. Before the interview, obtaining the patient's consent is mandatory. The interview phases include the preparatory phase, the introductory phase, the working phase, and the termination phase.
During the preparatory phase, the nurse prepares and identifies the patient to be interviewed, establishes an interview timeline, and selects a distraction-free place to meet.
Then, during the introductory phase, the nurse-patient relationship begins as the nurse states the interview's purpose. The patient is informed where the data is stored, the usage, and who can access the data. During the working phase, the nurse collects all information needed to create the subjective database. The database's completeness, accuracy, and relevance depend on the nurse's interviewing and communication techniques.
Successful interviews conclude carefully. During the termination phase, the nurse informs the patient that the interview is ending. As the interview ends, the nurse and the patient will review the data gathered, highlighting key points and ensuring all information is accurate. Ensuring accurate, essential data is collected is critical for the nurse-patient relationship and continuing with a patient-focused plan of care.
