Outcome 1 History taking
History taking is fundamental in a consultation and should incorporate not only physical health but their Psychological and Psychosocial information (Cox, 2004).
I have anonymised the patient so as to protect their identity in line with the Nursing, Midwifery code of professional conduct Council (2015).
I was asked to go and see Mr Brown who had been referred to the Reablement team on discharge from hospital following a fall at home which resulted in a fractured neck of femur requiring a partial hip replacement. The Reablement team were asked to support Mr Brown with personal care, meal preparation and regaining his confidence now he was home. He had been home from hospital for two weeks and had been doing well, however over the last few days he had become unwell and it was reported by the support workers that he had gone backwards in his rehabilitation programme. Mr Brown lives in his own privately owned house.
I arrived at Mr Brown’s house and as I was going in his neighbour was just leaving to go and get him some shopping, she expressed her concerns that he appeared very low in mood.
NEIGHBOURS FIRST STAGE CONNECTING:
On entering his home I found Mr Brown in the lounge, I introduced myself and showed him my identification and explained that I was the Nurse that supported
…show more content…
Subsequently I asked Mr Brown to explain what had been happening over the last week in terms of his health. He said that it had been longer than a week that he had not felt right. I asked him if he could explain in what way. He explained that a couple of days before his discharge he had had a slight cough but had not said anything in case the Doctor stopped his from coming