Why would nurse need to do this kind of interview

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Reference no: EM133697505

Question

Why would a nurse need to do this kind of interview and history? How did what you found out about your client differ from what you expected to find? What are the implications of your findings?

NURSING HISTORY

1. Identifying Data (Nursing history is to be obtained from patient interview, not from patient chart/kardex/computer.) A. Age, sex, race, source of information, reliability of the source (how did you determine the client was reliable?). Per the patient she was Alert and Oriented x 4 to who she was, where she was, the day of the week, and why she was in the hospital. Her speech was clear with behavior appropriate, 74 age, female.

2. Chief Concern A. "Why did you come to the hospital?" A direct quote in the patient's own words. "Came to the hospital torn quad muscle that happened after Dec19th total knee surgery."

3. History of Present Illness A. Narrative account of chief concern including duration, intensity, frequency, description, associated symptoms, and patient's actions (to alleviate symptom). Needs to cover events up to the time you took care of patient in hospital (This could include diagnostics and treatments). Needs to include admitting diagnosis. Admitting diagnosis, she was admitted.

Reference no: EM133697505

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