One of the most crucial steps in healthcare is conducting an assessment of a patient’s disease or condition to understand its genesis before subjecting the patient to further diagnostic procedures. A comprehensive assessment provides an overview of the patient’s condition, making healthcare providers to predict, and prepare suitable and relevant diagnosis (Lloyd, 2007). Therefore, for a comprehensive health assessment it is essential to have a knowledgeable and skillful nurse, a free and willing patient, proper assessment tools, as well as an enabling environment.
Nurses are always expanding their roles and responsibilities and it is likely that history taking will be performed by either a specialist nurse or a nurse practitioner. History taking is part of the comprehensive assessment, and it is mainly done by nurses. To accommodate patients who have never been to a healthcare facility, nurses need to provide an enabling environment, as well as use proper communication skills (AMN Healthcare Education Services, 2011). The main objective is to make the patients talk about their conditions. Therefore, nurses have to demonstrate patience and use both verbal and non-verbal cues to make the patient comfortable.
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The best techniques to gather data or information concerning patients’ conditions is through observations and asking questions. Some conditions such as injuries are observable, and in such cases, nurses only need to know when, where, and how the injury occurred. For conditions that are not observable, nurses need to devise a logical structure such as beginning with open-ended questions (How do you feel?), followed by close-ended questions (When did the pain start?) and then seeking clarification; reflecting on the responses and confirming with the patient what you have recorded (Lloyd, 2007). Evidently, a comprehensive health assessment requires the nurse to be compassionate, as well as considerate to the feelings of the patient. Consequently, the patient-nurse gap is reduced leading to free expression and better assessment.
References
AMN Healthcare Education Services. (2011). Overview of Nursing Health Assessment. Rn.com. https://lms.rn.com/getpdf.php/1736.pdf
Lloyd, H. (2007). A guide to taking a patient's history. Nursing Standard , 22 (13), 42-49.
