Data Collection, Health History and Self-Care Teaching

Scope of Practice and Health History Collection

In practical nursing, understanding your exact scope of practice is essential for safe care. The registered nurse is responsible for the initial comprehensive assessment, developing the primary nursing care plan, establishing nursing diagnoses, and providing initial client teaching. The practical nurse contributes to this process by collecting data, performing focused data collection on stable clients, and monitoring for changes in condition. When caring for clients, the practical nurse must promptly report acute changes in a client's status or abnormal data to the registered nurse.

Health history collection relies on gathering both subjective and objective data. Subjective data consists of information reported directly by the client, such as pain ratings, dizziness, and feelings of nausea. The client is the primary source of subjective history whenever they are able to communicate. Objective data consists of measurable and observable findings obtained through physical checks, diagnostic tests, and vital signs. Secondary data sources include family members, previous medical records, and reports from other healthcare team members. These secondary sources, along with caregivers, provide helpful supplemental information when needed.

When interviewing a client, document the chief concern in the client's own words whenever feasible. Use open-ended questions to encourage the client to provide descriptive details and clarify symptoms during history collection. For example, asking a client to describe how an issue impacts their daily routine invites a full, detailed response. In contrast, closed-ended questions are used to gather specific facts quickly or clarify details during focused data collection, such as asking whether a symptom began today.

Completing medication reconciliation data collection requires documenting prescription drugs, over-the-counter medications, vitamins, and herbal supplements. In addition, always ask about allergies, noting the specific allergen and the exact reaction experienced. If the client cannot recall specific details about an allergy or reaction, document those unknown details as unknown rather than leaving blank spaces.