Components of Comprehensive Health History

According to the textbook, the health history format is largely used to organize or structure patient information verbally or in writing. The goal of a health history is to gather information that will help the nurse and other healthcare providers understand the patient’s needs and concerns, as well as for diagnostic purposes.

In this case study, a full health history would be most relevant. This is because the patient is new to the clinic and the nurse needs to get personal information about the new patient. Comprehensive health history encourages the formation of a strong healthcare professional-patient relationship, which is essential for the effective treatment and general well-being of all patients.

Comprehensive health history also aids in the process of diagnosing the patient, by ruling out any illnesses based on what the patient is experiencing.

Lastly it is beneficial in the promotion of health and healthy behaviour, as it provides a platform for the clinician to educate and advise their patients

Components of Comprehensive Health History

Identifying data: This involves gathering information regarding the patient’s age, gender, occupation, and marital status.

Source of history: This is usually from the patient, but if the patient is unable to provide the clinician with their health history the source maybe from a friend, a family member, or medical records.

Reliability: depends on the patient’s mood, trust and memory.

Chief complaint: Refers to the main pain(s) or symptoms a patient may be suffering from.

Present Illnesses: This includes how the patient feels about their current condition. It also may help to explain how the chief complaint developed. This component of comprehensive health history may include, current medication, allergies and any habits they may have contributed to the present illness.

Past Histories: Refers to childhood illnesses, lists of adult illnesses that separated into four categories: surgical, psychiatric, medical, obstetric.

Family history. Refers to any illnesses that are prevalent in the patients’ families, such as; coronary diseases, hypertension, diabetes.

Personal and social history: This relates to the lifestyle choices, household and living conditions and personal interests.

Information documented:

The nurse could document subjective or objective data. Subjective information refers to the information the patient gives you regarding their illness. This could be what the patient is feeling, and the symptoms the patient is experiencing.

Objective data is the information obtained after conducting a physical examination of the patient. This pertains to patient’s heartrate, weight, height etc.

The nurse is most likely to complete a focused health history, should the patient return to the clinic seeking medical attention again. This is because the patients personalized information is already document, and medical records are available for them. It also allows for swift medical attention and treatment particularly during routine check-ups or emergency calls. The clinician is most likely to focus on the symptom or illness the patient is experiencing relating to a specific body system.

Case study: Cultural and Spiritual Assessment.

In order for clinicians to deliver the best suited and competent healthcare to their patients, it is vital for them to practise “Cultural Humility”.

Cultural Humility can be described as process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It is a process that includes ”the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients’ health outcomes.”45 Murray-Garcia, J. Trevalon,M)

Cultural humility is a fundamental emotional tool for clinicians to rectify the imbalances that are observable in patient-clinician relationships as well as sustain a relationship amongst the healthcare professionals, patients and community that is beneficial to all parties involved.

If one is not conscious or aware of themselves, it proves difficult to be aware and have the ability to empathize with others. If a nurse does not practise cultural humility, they may unconsciously start developing cultural stereotypes towards patients of different cultures and beliefs, and this will in turn impact the healthcare service they issue their patients.

In this case, the best thing to do is to ensure that you fully understand the parents and to take down the health history as accurately as possible. If there is a language barrier between the patient’s parents and yourself, try and find an interpreter or an effective way of communication (Google translator, etc)

Another important thing is to take the Japanese parents through the entire treatment process and explain everything in necessary detail. Try and articulate yourself in a way that they will understand, and always ensure that they are comfortable with your method of treatment. These procedures are very important in building strong patient-nurse relationships, and ensures the best healthcare treatment for all parties involved.

Part 2:

The best approach for the general oncology nurse would be to offer the patient comprehensive counselling on their condition. There are important factors you need to cover in the counselling of the patient and these include:

Explaining to the patient what illness they suffer from exactly.

Explain how the healthcare personnel came to that diagnosis

Tell the patient the methods of treatment are available for their condition

Explain the implications/repercussions of each treatment method

Offer them support and a empathetic shoulder to cry on. It may also be comforting for the patient to know that their condition was beyond their control, and they have no reason to feel guilty about it

It is also essential to arrange a session with the patient’s loved ones an explain the patient’s illness to them. Go into detail about the treatment options, and what the patient is likely to experience during their treatment. The nurse should be as empathetic to the family as possible. Also provide the family with suggestions on how to cope with the patient’s condition, and how to be supportive to the patient to ensure the most positive outcome for all involved.