Nursing histories for better patient care

The article about patients not recalling their medications brought back many memories from when I was working in the hospital. When patients are admitted, nurses do a nursing history that is quite similar to the medical history, but with a different goal. Although the patients have already been asked many questions, our questions were geared towards helping us understand our patients to be able to give good patient care. The more we learned about our patients, the better we could care for them.

One question that would get a lot of confused answers would be “what medications are you on?” So many patients, especially the older ones, would say, “the white one for diabetes, the blue one for high blood pressure…” Trying to track down which medication and which dosage wasn’t always easy. Challenging would be a good word. :-)

Other questions we asked were sometimes met with suspicion. We would ask what the bowel and sleeping habits were normally. I remember some families members getting really upset over these questions. The stress of their loved one being ill, the stress of the admission and all that went into it, and now they were being asked questions that seemed useless to them. I would explain knowing what is usual at home helps us a lot in the hospital. For example, if we have admitted someone who only has a bowel movement every three days, we’re not going to start pushing laxatives after 24 hours. If a patient usually stays up until 2 a.m., we’re not going to worry if they’re still awake at midnight.

Even questions such as if someone lived alone, if there were stairs in the home, and about living arrangements. These are all important issues. Nurses need to know what people are like at home in order to judge if they are having problems in the hospital. Equally important, nurses need to know what type of living situation the patient is going to be discharged to.

Most of us are aware that by the time we are doing the nursing assessment and nursing history, the patients have been poked and prodded more than they thought was humanly possible, and they have been asked questions until they can’t think straight any more. But, it’s also important to remember that nurses have a different take on patient care and the answers patients give nurses are for different goals than the answers patients give doctors.

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