Nursing Histories Can Tell You More Than You Realize

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When I began working as a nurse, my first few attempts at getting a thorough nursing history were quite interesting. Little did I know that I would be expected to get all this information in the ER.

How do you feel about taking nursing histories? Do you find that they’re useful? What types of questions do your nursing histories have?

When I began working as a nurse, my first few attempts at getting a thorough nursing history were quite interesting. Little did I know that I would be expected to get all this information from someone who had already answered many of those questions — and more – in the emergency room.

To someone who isn’t used to answering questions or has never come across a nursing history, questions like “do you have any stairs in your home” or “what time do you usually go to bed” may seem very intrusive. I once had a patient ask me why I needed so much information about her home — was I planning on coming to rob her? It took a lot of convincing for her to understand that it was because we needed this information (the stairs) for discharge planning and the time of sleep so that if we knew she was a night owl, we wouldn’t be concerned if she was wide awake at midnight but dead tired at 9 am.

I know that we used to laugh off some of the responses we’d get when doing the histories, but every once in a while, the importance of these documents was brought home. A good friend of mine admitted a patient for cataract surgery — back in the days when you stayed overnight before and after. She was doing the nursing history and asked if he drank alcohol. “No,” he answered, he didn’t drink.

Later on the history, as they discussed diet, she asked if he drank coffee or tea. “Coffee,” he replied. She asked what he put into it. “Brandy, a shot of brandy in each cup of coffee,” he answered. Out of curiosity, she asked how many cups of coffee he drank in a day. The answer? Fifteen or 20 cups a day. With a shot of brandy in each one.

The man ended up experiencing a lot of problems after the surgery because of withdrawal from his “coffee” habit but the staff knew what was causing it. If my friend hadn’t had probed further, she would never have found out that the man did, indeed, drink a significant amount of alcohol every day.

Of course, that story is a bit extreme, but it shows us that it can happen. Social drinking to me may be completely different to someone who feels drinking six beers a day is social drinking. Asking someone if they smoke might give you the answer “no,” but maybe they smoke marijuana every day.

I had one patient once tell me that she took Tylenol every day, morning and night. She pulled out her bottle, which contained not just Tylenol, but acetaminophen with a significant amount of codeine — a prescription medication.

So, perhaps that nursing history is more important than the credit we give it. What’s the oddest nursing history story you’ve ever come across?

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