Nursing history as a fundamental element of nursing assessment and nurses’ communication skills in effectively taking a nursing history

Abstract

Nursing assessment is the first step, of the nursing process in planning a documented, excellent nursing care, for the patient. It includes the assessment of health status, problem recognition, needs and risk factors for the health of the patient. A fundamental element of assessment, is the collection of data achieved, through various strategies, most importantly the acquisition/taking a/ of a nursing history. The purpose of this article is to introduce the process of the medical history acquisition, as an integral part of nursing assessment, describing nurses’ communication skills, in effectively receiving and recording data. The history taking, achieved by developing interpersonal communication nurse - patient, with special skills in verbal and nonverbal communication of nurses. With behavior that manifest understanding acceptance and positive attitude, facilitate data collection, contributing to the planning of nursing interventions and the positive outcome of treatment problems. The Essentials, of a complete health history, with biographical data include: the Main symptomata, previous health history, current lifestyle, psychosocial status, psychiatric history and work environment, history of drug and sexual health, family history and evidence from the review of systems. The ability to collect a complete nursing history and physical examination, enhance critical thinking nurses, to solve the problems of the patient and improve the relationship between them, giving the opportunity for immediate and long-term care planning, implemented in the holistic perspective approach of the person.