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Lesson 14. the Nursing History

1-14. THE NURSING HISTORY

a. When obtaining the nursing history of a gastrointestinal patient, a detailed interview should be conducted. Nursing personnel should question the patient about his dietary habits, his bowel habits, and his GI complaints (signs and symptoms).

b. Obtaining a history of dietary habits will provide valuable information. Question the patient about the following:

(1) The number of meals ate per day.

(2) Meal times.

(3) Food restrictions or special diets followed.

(4) Changes in appetite. Increased? Decreased? No appetite?

(5) What foods, if any, have been eliminated from the diet? Why?

(6) What foods are not well tolerated?

(7) Alterations in taste.

(8) Medications used. Dosage and frequency.

c. Information about bowel patterns, especially a change in bowel patterns, can provide clues that will aid in the diagnosis of the problem. Question the patient about the following:

(1) Frequency of bowel movements.

(2) Use of laxatives and/or enemas.

(3) Changes in bowel habits.

(4) Stool Description.

(a) Constipation.

(b) Diarrhea.

(c) Blood in stool.

(d) Mucous in stool.

(e) Black, tarry stools.

(f) Pale or clay colored stools.

(g) Foul smelling stools.

(h) Pain with stool.

d. Ask the patient to describe any complaints not yet discussed in the interview. For example.

(1) Nausea. Frequency? Duration? Associated with meals? Relieved by?

(2) Vomiting. Frequency? Character of emesis? Relieved by?

(3) Heartburn/indigestion. Frequency? Duration? Associated with specific foods? Relieved by?

(4) Gas (belching and flatus). Frequency? Associated with specific foods? Relieved by?

(5) Pain. Location? Frequency? Duration? Character of the pain?

(6) Weight loss. How much? In what time period?

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