Anamnesis (care)
Nursing anamnesis (Greek: anamimneskein, to remember) is a collection of data about a patient and their background (e.g. family, living environment, experiences, memories) that can be used in the analysis of the patient's state of health. Thus, the maintenance history forms the basis for the nursing process to implement, to plan for the care and thus an optimal nursing practice permit.
Differentiation from the medical anamnesis
The medical history is used to establish the diagnosis and thus the treatment of the disease. The nursing history is aimed at planning health care and nursing care. In addition, the effects of the disease on the patient and his family as well as the need for advice and information should be assessed. And, ultimately, it already serves to prepare for discharge .
Action
The nursing history often takes the form of an interview , ideally as a dialogue , by a professional nurse . The following sources of information can be used in the nursing history:
- Interviewing the patient and / or his relatives
- Patient observation , if necessary appropriate assessment instruments (e.g. pressure ulcer scale )
- spontaneous statements by the patient, his relatives , fellow patients and other conversations
- Medical history , test results and referral diagnosis
- Nursing reports and transition reports from other wards , previous hospital stays or supervising outpatient care services
- Team members and members of other professional groups involved in the care of the patient
The information obtained can be distinguished:
- according to the source of information into direct and indirect information
- according to information type into subjective and objective information
The collection of information is often structured according to a particular nursing theory , e.g. B. the ATL to Juchli .
The anamnesis interview should be carried out by qualified nursing staff or under their guidance. It is the specialist knowledge of professional caregivers that makes it possible to analyze and interpret the data collected.
The nursing history is usually supported by standardized documents such as B. a questionnaire. On the one hand, these instruments are intended to provide a guide for the nursing staff so that they can structure the anamnesis discussion. On the other hand, the use of standardized instruments creates a comparability between the individual anamneses and guarantees a constant standard.
The discussions are structured according to the usual rules of interviewing . It is usually recommended that the anamnesis interview be conducted within 48 hours of admission. However, the gathering of information is a continuous process that extends over the entire stay of the patient. So if new information is added, the nurse has to review their care planning for changes.
Dimensions
Depending on the focus of the anamnesis and who is providing information, a distinction can be made according to various dimensions:
- Personal history (information provided by patients about themselves)
- Biographical anamnesis (information on life history)
- Family history (information on illnesses in the family, relationships, roles and behavioral patterns that have developed over time in living together)
- Social history (information on the social environment, social situation and livelihood security).
An anamnesis that includes all the dimensions listed is also called a full anamnesis.
Aspects of a full medical history
The following aspects are recorded as part of a full medical history:
- Current complaints
- Personal data and life situation
- General illness-related physical data / information / biography
- General and illness-related psychological data / information / biography
- Preferences, habits, routines
- social environment
An anamnesis can, however, also take place in partial areas (e.g. a family or social history) or set certain priorities (e.g. a pain history).
Forms of anamnesis
Standardized (checklist)
The standardized anamnesis with the help of a checklist is identified by closed questions or by given answers. The individually queried aspects do not have to follow any logic in terms of time or content. Often the closed questions are combined with the possibility of formulating them yourself (so-called free text). The advantage lies in the fact that data can be easily objectified. The disadvantage is that, although relevant knowledge is gained from a nursing point of view, this is not necessarily essential for the person in need of care.
Open form of anamnesis (narration)
This form of anamnesis provides information about personal aspects associated with the disease. The methodological basis is the narrative interview .
Legal basis
The nursing anamnesis is one of the self-responsible activities of the training occupations for professional nurses. The legal basis in Germany results from the Nursing Act §3: "The training for nursing according to paragraph 1 should enable in particular to 1. carry out the following tasks independently: a) Survey and determination of the nursing needs, planning, organization, implementation and documentation of care ". There is also an obligation to take a nursing history from the quality test guidelines of the Medical Service of the Health Insurance Fund (MDK).
In Austria, personal responsibility arises from GuKG § 14: "The self-responsible field of activity includes in particular: 2) Assessment of the care needs and the degree of care dependency of the patient or client as well as determination and assessment of the resources available to cover these needs (care history)" .
See also
literature
- Harald Stefan u. a .: Practice of nursing diagnoses. Springer-Verlag, Vienna / New York 1999, ISBN 3-211-83244-0 .
- Nicole Menche (ed.): Care today. 4th edition. Elsevier, Munich 2007, ISBN 978-3-437-26771-0 .
Individual evidence
- ↑ Kenneth A. Anderson (ed.): Springer Lexikon Pflege . Springer-Verlag, Berlin 2004.
- ↑ Harald Stefan: Practice of nursing diagnoses . Springer-Verlag, Vienna / New York 1999.
- ↑ Nicole Menche: Care today . 4th edition. Elsevier, Munich 2007.
- ↑ a b Berta M. Schrems: Assessment of nursing needs - The assessment as part of nursing diagnostics . 1st edition. HFH Hamburger Fern-Hochschule, Hamburg 2009.
- ↑ Nursing Act. §3 training objective. Retrieved January 8, 2014 .
- ↑ MDK instructions for checking the quality according to §§ 112, 114 SGB XI in outpatient care. (PDF) (No longer available online.) November 10, 2005, p. 91 , archived from the original on January 8, 2014 ; accessed on January 8, 2014 : “The tasks of these nursing staff include a. the nursing history / actual survey, ... “ Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ Health and Nursing Act. §14 Responsible area of activity. Retrieved January 8, 2014 .
