When collecting the medical history of a client, the nurse would typically engage in the assessment phase of the nursing process. The nursing process consists of five interconnected steps: assessment, diagnosis, planning, implementation, and evaluation. Each step serves a specific purpose in delivering holistic care to the client.
During the assessment phase, the nurse gathers comprehensive and relevant information about the client's health status, including their medical history. This process involves actively listening, asking appropriate questions, and utilizing various assessment techniques to collect subjective and objective data. The nurse may inquire about the client's current and past medical conditions, previous surgeries, allergies, medications, family medical history, lifestyle factors, and other pertinent information.
By collecting the client's medical history, the nurse gains essential insight into the client's overall health, previous diagnoses, treatments, and potential risk factors. This information aids in formulating an accurate nursing diagnosis, developing an appropriate care plan, and implementing interventions tailored to the client's specific needs.