Initial Questions to Ask Mr. Sykes for Accurate Patient History Assessment

The article discusses the initial questions to ask Mr. Sykes for an accurate patient history assessment. It explains the rationale behind each question and its importance. The questions are categorized based on the symptoms presented by the patient.

Running head: NURSING
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Initial questions to ask Mr. Sykes and the rationales for these questions
The aim of carrying out an accurate patient history assessment is to understand the
underlying factors leading to the presentation of the patient at the healthcare unit. The approach
of undertaking the assessment depends of the condition of the patient and the urgency
demonstrated by the patient presentation (Tagney, 2008). In the present case Mr. Sykes has
presented to the care unit with a multiple symptoms such as explosive watery diarrhea, nausea
and left abdominal pain. It is crucial that the nurse carries out a successful investigation of the
patient condition with the help of certain questions.
Introductory questions-
 Hello Mr. Sykes how are doing? Seems you are in much discomfort.
 Can you please tell me your age and your present address?
 Who do you have as your family members? Have they come with you?
 What do you do for a living?
Rationale- A nurse is the first point of care when a patient presents to the healthcare unit with
varying symptoms. It is therefore crucial that a nurse establishes an effective therapeutic
relationship at the initial stage of conversation so that further care delivery is articulated in an
effective manner (Moorhead, Johnson, Maas & Swanson, 2018).
Questions regarding pain in left abdomen-
 When did you start feeling the pain?
 Have you felt such pain before?
 Which is the exact site of pain and is it radiating to other directions?

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 Are you having any other symptoms?
 Is the pain getting worse?
 Is any factor making the pain worse?
 Please rate the pain on a scale of 1 to 10
Rationale- The use of SOCTATES mnemonic for more details of pain symptoms is helpful in
understanding the care needs for a patient. Pain in the left abdomen might be related to
conditions of the liver and intestine. The questions mentioned would aid in early diagnosis of the
condition that the patient is suffering from (Jangland, Kitson & Muntlin Athlin, 2016).
Questions regarding diarrhea and nausea-
 How many times have you passed stool in the last one day?
 How do you describe the colour and consistency of the stool?
 Have you noticed blood in your stool?
 Do you feel nausea only after vomiting?
 Have you noticed blood while vomiting?
Rationale- The above questions would help in understanding the cause of diarrhea. The link
between diarrhea and ulcerative colitis would be established in the patient through the
assessment. The answer to these questions along with the answers to the questions on pain would
help in accurate diagnosis (Muhrer, 2014).
Questions regarding past medical and drug history-
 When did you last visit a general physician?
 Do you have heart conditions, high blood pressure or diabetes?

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 For how long are you taking ibuprofen?
 Are you allergic to any particular drug?
Rationale- Knowledge of past medical conditions and drug history is essential for outlining
medication treatment for a patient. Further, possible risk of adverse effects due to
pharmacological interventions can be avoided (Ingram, 2017).
Questions regarding social history-
 For how long have you been smoking?
 How many packs cigarettes do you smoke in a week?
 How much do you drink in a week?
 Do you have a family history of any such similar conditions related to GI system?
 Can you please briefly describe your daily food intake?
Rationale- Smoking and excessive drinking has been linked with gastrointestinal conditions
whose health impact is adverse. Family history assessment helps in understanding the risk factors
for developing GI disorder (Moorhead, Johnson, Maas & Swanson, 2018).

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References
Ingram, S. (2017). Taking a comprehensive health history: learning through practice and
reflection. British Journal of Nursing, 26(18), 1033-1037. DOI
https://doi.org/10.12968/bjon.2017.26.18.1033
Jangland, E., Kitson, A., & Muntlin Athlin, Å. (2016). Patients with acute abdominal pain
describe their experiences of fundamental care across the acute care episode: A multi‐
stage qualitative case study. Journal of advanced nursing, 72(4), 791-801. DOI
https://doi.org/10.1111/jan.12880
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2018). Nursing Outcomes
Classification (NOC)-E-Book: Measurement of Health Outcomes. Elsevier Health
Sciences. Retrieved from https://books.google.co.in/books?
hl=en&lr=&id=LYlIDwAAQBAJ&oi=fnd&pg=PP1&dq=nursing+assessment,
+book,&ots=bOUtY1zwbQ&sig=NcZgcdu_4wycNhKvH1CWQP-
dRr0#v=onepage&q=nursing%20assessment%2C%20book%2C&f=false
Muhrer, J. C. (2014). The importance of the history and physical in diagnosis. The Nurse
Practitioner, 39(4), 30-35. DOI 10.1097/01.NPR.0000444648.20444.e6
Tagney, J. (2008). Skills in taking an accurate cardiac patient history. British Journal of Cardiac
Nursing, 3(1), 8-13. DOI https://doi.org/10.12968/bjca.2008.3.1.27994