如何全面了解患者病史。

Sarah Butler
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引用次数: 0

摘要

理由和要点:很大一部分诊断是根据病史做出的,通常还要进行体格评估和实验室检查。全面采集病史是准确诊断和有效管理健康状况的基础。本文概述了全面采集病史的逐步过程,并讨论了这一过程的证据。- 病史采集是一个有条理但灵活的过程,通过采集患者的相关信息为诊断和治疗提供依据。- 护士在采集病史时需要掌握的重要沟通技巧包括积极倾听、移情沟通和文化敏感性。- 通过积极与患者就其健康问题进行交谈,护士可以促进患者的参与和自主性。反思活动:"如何 "文章有助于更新您的实践,并确保其始终以证据为基础。将这篇文章应用到你的实践中。思考并写一篇简短的文章:- 这篇文章如何改进你在采集病史时的做法。- 您如何利用这些信息教育护理专业学生或同事如何采集病史。
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How to take a comprehensive patient history.

Rationale and key points: A significant proportion of diagnoses are made based on history taking, often alongside physical assessments and laboratory investigations. Taking a thorough patient history is fundamental for the accurate diagnosis and effective management of health conditions. This article outlines a step-by-step process for taking a comprehensive patient history and discusses the evidence for this procedure. • History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment. • Important communication skills for nurses when history taking include active listening, empathetic communication and cultural sensitivity. • By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your practice when taking a patient history. • How you could use this information to educate nursing students or colleagues on taking a patient history.

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