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Section 1: Overview
1. Purpose of Inquiry Inquiry is a systematic process where nurses purposefully and methodically ask patients or informants to obtain health-related information. The information obtained through inquiry is subjective data. The purpose of inquiry is to identify the patient’s subjective feelings of abnormalities or discomfort, understand the occurrence, development, diagnosis, treatment, and nursing process of the disease, previous health status, history of diseases, and responses in physiological, psychological, and social aspects. Inquiry is the first step in initiating nursing care and is also an important opportunity for nurses to establish a positive therapeutic relationship with patients.
2. Content of Inquiry (1) Physiological-Psychological-Social Model 1. Basic Information: Includes name, gender, age, occupation, ethnicity, place of origin, marital status, religious beliefs, home address, payment method for medical expenses, admission time, diagnosis, type of admission, reliability of data sources, and the time of data collection. If the source of information is not the patient themselves, the relationship to the patient should be noted.
2. Chief Complaint: The most significant and obvious symptoms or signs felt by the patient, including their nature and duration, which is the main reason for the patient’s visit. A precise chief complaint can initially reflect the severity and urgency of the condition. 3. Present Illness History: A detailed description of the patient’s health issues since the onset of the disease, including the occurrence, development, evolution, diagnosis, treatment, and nursing process. This includes: ① Onset situation and duration of illness: The onset situation includes the environment and circumstances of the onset, while the duration refers to the time from onset to the visit or admission. ② Causes and triggers ③ Characteristics of main symptoms: location, nature, duration, frequency of occurrence, severity, and any factors that may aggravate or alleviate the symptoms. ④ Accompanying symptoms: Other symptoms that appear simultaneously or subsequently with the main symptoms. ⑤ Development and evolution of the condition ⑥ Diagnosis, treatment, and nursing process.
4. Daily Living Conditions: Helps identify any adverse lifestyle behaviors that the patient may have, and based on the patient’s different habits, find suitable methods to help maintain and restore health. Main content: dietary and nutritional patterns, excretion patterns, rest and sleep patterns, daily living activities and self-care abilities, personal preferences.
5. Past Medical History: Previous health status and experiences of hospitalization. This includes ① Previous health status, ② Time of previous diseases, main manifestations, treatment process, and outcomes, ③ History of trauma, surgical history, and hospitalization experiences, ④ Allergy history.
6. Personal History: Includes birth and growth conditions, menstrual history, and reproductive history. 7. Family History: Mainly to understand the health status, diseases, and mortality of direct relatives. 8. Psychological and Social Status
(2) Functional Health Patterns Model proposed by Major Gordon in 1987, involving 11 functional patterns related to physiological, psychological, and social aspects. 1. Basic Information: Same as the physiological-psychological-social model. 2. Chief Complaint: Same as above. 3. Present Illness History: Same as above. 5. Functional Health Patterns: (1) Health perception and health management pattern (2) Nutritional and metabolic pattern (3) Excretion pattern (4) Activity and exercise pattern (5) Sleep and rest pattern (6) Cognitive and perceptual pattern (7) Self-concept pattern (8) Role and relationship pattern (9) Sexuality and reproductive pattern (10) Stress and coping pattern (11) Values and beliefs pattern 3. Methods and Skills of Inquiry (1) Basic Principles 1. The environment should be quiet, comfortable, and private. 2. Respect, care for, and protect the inquiry subject. 3. Appropriately use communication skills to ensure the comprehensiveness, authenticity, and accuracy of the information.
(2) Preparation Before Inquiry ① Preparation of inquiry content: Master the main content of inquiry and the order of questions. ② Anticipate possible issues and necessary measures. ③ Choose an appropriate environment and timing. (3) Common Methods and Skills During Inquiry 1. Provide explanations and self-introductions. 2. Proceed gradually and unfold the inquiry step by step. 3. Use appropriate questioning forms: open-ended questions, closed questions. Avoid leading questions. 4. Avoid using medical jargon. 5. Maintain an accepting and respectful attitude. 6. Stay on topic or return to the main topic. 7. Non-verbal communication skills: appropriate distance, eye contact, smiling, nodding, gestures, touch, contemplation, listening, etc. 8. Timely verification of information: clarification, repetition, rephrasing, questioning, analysis, etc. 9. At the end of the inquiry, provide hints or prompts.
4. Special Situations in Inquiry
(1) Emotional Abnormalities
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Anger and hostility: Nurses must not become angry or feel wronged or humiliated; they should maintain a calm, understanding, and respectful attitude. For angry patients, questions should be asked slowly and clearly, focusing mainly on the present illness history. Sensitive questions should be approached cautiously or asked in parts. If the patient’s emotions become uncontrollable, the nurse should pay attention to their own safety.
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Anxiety and depression: Provide appropriate comfort and reassurance, and be mindful of the balance; use direct questions more during the inquiry and pay attention to emotional communication with the patient.
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Silence and sadness: Provide comfort, understanding, and appropriate waiting.
(2) Elderly and Children
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Elderly: Use simple, clear, and easily understandable general questions, slow down the speaking pace, and raise the volume. Allow sufficient time for thought, appropriate repetition, face-to-face communication, and pay attention to responses; if necessary, gather information from family and friends.
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Children: Information should be provided by parents or guardians.
(3) Critically Ill and Terminal Patients
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Critically ill: Focus on assessing the current main issues while simultaneously providing rescue.
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Terminal patients: Conduct inquiries based on the specific situation of the patient, striving to provide honest and reliable answers to the patient’s questions, and offer emotional support.
(4) Cognitive Dysfunction: Inquire with the patient’s relatives, witnesses, or other medical personnel to obtain medical history information.
(5) Different Cultural Backgrounds
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Distance and touch
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Eye contact
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Ways of expressing emotions or pain
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Language expression