7.3:
Data Collection II
Taking a nursing history is one method of data collection.
The nursing history captures and records the patient's biographical information and their history of present and past health, family, environmental, psychosocial, and spiritual health.
An interview is an effective way of gathering data for a nursing history.
Before beginning the interview, obtain the patient's verbal consent.
The four phases of the interview are the preparatory, introductory, working, and termination phases.
During the preparatory phase, the nurse identifies the patient, reviews records, plans time, and decides on a quiet, distraction-free location.
Then, during the introductory phase, the nurse-patient relationship is established. The patient should be assured of confidentiality and informed about data storage, usage, and accessibility.
In the working phase, the nurse collects subjective data using communication techniques, such as asking open-ended questions.
Patient variables like anxiety, pain, language difficulty, prior negative experience, or an unrealistic expectation of healthcare can affect the interview outcome positively or negatively.
Finally, in the termination phase, after the required data is collected, the interview is concluded.
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.