HISTORY TAKING

Aim.
• To obtain data that will enable the nurse to
– make a nursing diagnosis,
– identify and implement nursing interventions
– assess effectiveness of nursing interventions.
• To establish a relationship with the patient.
 Art of history taking
• History-taking is a special form of
communication.
• The beginning of nurse – patient relationship.
• Put the patient at easy and encourage him to
talk freely.
• Be friendly, say who you are and your role.
• Observe the patient’s face from time to time
and try to establish eye contact.
• If you are embarrassed try not to show it.
• Introduce yourself by name and establish the
patient’s identity, age, and address, and make
the patient feel at ease.
• Open the consultation with some general
question such as “ what can I do for you? Or
“How can I help you? Or “what’s the trouble?
• This gives the patient an opportunity to begin
the consultation, and encourages relevance.
• If you are a student do not mask the fact.
• Understand the patient’s full name and that
you pronounce it correctly.
• Address the patient properly ( Mr, Mrs, Miss).
• Never use a surrogate term for the patient’s
name, e.g. mother, father.
• Be seated at an easy distance from the
patient, comfortably and without any
furniture barriers between you.
• Listen to the patient carefully.
• Avoid interruptions unless you really have to.
• the person has the right to know why the
information is sought and how it will be used
 Sensitive issues.
• Not easy to question a patient on sensitive
issues like sex, sexual orientation drug or
alcohol use or concerns about death.
• Still they must not be avoided.
• There is no specific “right” way to deal with
these questions but you must feel comfortable
with your approach.
 Guides to questioning.
• Privacy is essential
• Do not waffle, be direct and firm.
• Do not preach.
• You are not there to pass judgment.
• Use language that is understandable to the
patient, yet not patronizing.
• Do not push too hard.
• If the patient is defensive, recognize that the
patient feels that defense is necessary.
 OUTLINE OF CLINICAL HISTORY.
Biographical data
• Personal details of patient
• Includes
– name,
– address,
– age,
– gender,
– marital status,
– occupation,
– ethnic origins.
Chief Complaint:
• What really made the patient seek care
• Questions to ask
– “what problems or symptoms brought you here?”
– “Why have you come to the health center today?”
– “Why were you admitted to the hospital?”
• The duration of the illness should be
determined.
History of Presenting Illness:
• Details of the current problem i.e. analysis of
s/s
• Recorded in chronological order from onset to
the time of contact with health care provider
e.g.
– Patient was well until ……
– The patient first experienced head ache 1 month
before seeking care
• State of health just before the onset of the
present problem.
• Possible exposure to infection or toxic agents.
• Immediate reason that prompted the seeking
of attention.
• Medication: current and recent, including
dosage of prescription and home remedies.
• Impact of the illness on the patient’s usual
life-style ( marriage, leisure activity).
• “Stability” of the problem, does its intensity
vary.
• How problem started i.e. onset
– Date and manner (sudden or gradual) in which the
problem occurred
– setting in which the problem occurred (at home,
at work, after an argument, after exercise),
– manifestations of the problem,
– the course of the illness .
– Treatments taken, progress and effects of
treatment, and the patient’s perceptions of the
cause or meaning of the problem.
• Specific symptoms are described in detail
– location and radiation (if pain),
– quality,
– Severity
– duration.
• Is problem persistent or intermittent,
– what factors aggravate or alleviate it,
– associated manifestations.
Past Medical History
• A detailed summary of client’s past health
• Helps in assessing the present complaint.
• Assists the nurse to identify risk factors that
stem from previous health problems
• Includes
– General health status.
– Childhood illnesses:
• measles,
• mumps,
• whooping cough,
• poliomyelitis,
• acute rheumatic fever.
– Major adult illnesses:
• tuberculosis, hepatitis, diabetes, hypertension, heart
diseases.
– Immunization status:
• polio, diphtheria, pertussis, tetanua toxoid, influenza,
cholera, typhus, bacilli Calmette-Guerin(BCG) etc.
– Surgery and hospitalization:
• dates, hospital, diagnosis, complications.
– Serious injuries and resulting to disability.
– Limitation of ability to function as desired as a
result of past events.
– Medications:
• past, current and recent medications
– Allergies
– Transfusions:
• reactions, date, number of units transfused
– Emotional status: mood disorders,
– psychiatric disorders.
– Previous investigations and results
• Sample questions
– Birth.
• “Can you tell me how your mother described your
birth?
• Were there any problems?
• As far as you know, did you progress normally as you
grew to adulthood?
• Were there any problems that your family told you
about or that you experienced?”
– Childhood diseases & immunization
• “What diseases did you have as a child such as measles
or mumps?
• What immunizations did you get and are you up to date
now?”
– Chronic illness
• “Do you have any chronic illnesses?
• If so, when was it diagnosed?
• How is it treated?
• How satisfied have you been with the treatment?”
– Previous illness/allergy
• “What illnesses or allergies have you had?
• How were the illnesses treated?”
– Hospitalizations/surgery
• “Have you ever been hospitalized or had surgery?
• If so, when?
• What were you hospitalized for or what type of surgery
did you have?
• Were there any complications?”
– Accidents/injuries
• “Have you experienced any accidents or injuries?
• Please describe them.”
– pain
• “Have you experienced pain in any part of your body?
• Please describe the pain.”
– Mental problems
• “Have you ever been diagnosed with/treated for
emotional or mental problems?
• If so, please describe their nature and any treatment
received.
• Describe your level of satisfaction with the treatment.”
Family History:
• Ask if there is blood relatives in the patient’s
family who have illnesses with features similar
to the patient’s illness.
• Determine the ethnicity, health, or cause of
death of parents and siblings, including their
ages at death.
• If there is a hereditary disease such as sickle
cell disease
– inquire into the history of grandparents, aunts,
uncles, siblings and cousins concerning hereditary
diseases.
• Establish whether there is a history of heart
disease, high blood pressure, cancer,
tuberculosis, stroke, epilepsy, diabetes,
asthma, blood diseases allergic states or any
other familial disease.
Personal and Social History:
• Personal status
• birthplace, where raised, home environment,
socioeconomic class, cultural background, education,
position in family, marital status, general life
satisfaction, hobbies, interests, sources of stress,
strain.
• Habits
• nutrition and diet, regularity and patterns of eating
and sleeping, exercise, alcohol, illicit drugs(frequency,
type and amount), quantity of tea, coffee, tobacco,
breast or testicular self examination.
• Sexual history
– concerns with sexual feelings and performance,
frequency of intercourse, ability to achieve
orgasm, numbers and variety of partners.
• Occupation
– description of usual work and present work if
different, list of job changes, work conditions and
hours, duration of employment
• Religious preferences
– determine any religious proscriptions concerning
medical care.
Review of Systems.
• All major systems are reviewed
• client is asked specific questions to draw out
current health problems or problems from the
recent past that may still affect the client or
that are recurring.
• Include only the client’s subjective
information and not the examiner’s
observations.
• Helps reveal any relevant data.
– General
• weight, sleep, energy
– GIT, abdomen and pelvis
• pain, appetite, vomiting, general characteristics of
vomited matter, flatulence, heartburn, dysphagia,
diarrhoea, constipation.
• Liver and gall bladder – jaundice, pain.
– Genital system
• ulcers, discharge, pain.
– Cardiovascular system
• Dyspnoea, pain or tightness, palpitation, cough, edema,
other symptoms.
• The blood
– Dyspnoea and awareness, infections, blood loss, skin
problems, diet, past history, drug history
– Respiratory system
• Cough, sputum, breathing, wheeze, chest pain.
– Urinary system
• symptoms suggestive of renal failure, urine
– Nervous system
• stroke, epilepsy, common neurological symptoms.
– Locomotor system
• muscles
– tonicity
• Infants and children
– special questions where relevant.
 Children.
Chief complaint:
• History taken from a parent or other
responsible adult.
• However, the child must be included as much
as possible as appropriate for his/her age.
• The latent fears underlying any chief
complaint of both parents should be explored.
• Note the relationship of the person providing
the history for the child.
 Present Problem or Illness.
• The degree and character of the reaction to
the problem on the part of parent and child
should be noted.
 Past Medical History:
• General health and strength
– depending on the age of the patient or nature of
the problem, different aspects of the history
assume or loose importance;
– reserve detailed questioning for those aspects
most pertinent to the age of the child.
• Mother’s health during pregnancy
– general health, prenatal care.
– Specific diseases or conditions;
• infectious disease (approximate gestational month),
weight gain, edema, hypertension, proteinuria,
bleeding.
– Medications, hormones, vitamins, special or
unusual diet, general nutritional status.
– Quality of fetal movements and time of onset.
– Emotional and behavioral status(attitudes toward
pregnancy and children).
– Radiation exposure.
– Use of illicit drugs.
• Birth
– duration of pregnancy, place of delivery.
– Labor:
• spontaneous or induced, duration, analgesia or
anesthesia, complications.
– Delivery:
• presentation, forceps, vacuum extraction, spontaneous
or caesarian section; complications.
• Condition of infant, time of onset of cry, apgar score.
• Birth weight of infant.
• Neonatal period
– congenital anomalies; baby’s condition in hospital,
oxygen requirements, colour, feeding
characteristics, vigor, cry;
– duration of baby’s stay in hospital and whether
infant was discharged with mother;
– bilirubin phototherapy, prescriptions(e.g.
antibiotics).
– First month of life
• jaundice, color, vigor of crying, bleeding, convulsions,
or other evidence of illness.
– Degree of early bonding
• opportunities at birth and during the first days of life
for the parents to hold, to talk, and caress the infant(
opportunities for both parents to relate to and develop
a bond with the baby)
• Feeding
– bottle or breast, reason for changes if any; type of
formula used, amounts offered and consumed,
frequency of feeding and weight gain.
– Present diet and appetite; age of introduction of
solids; present feeding patterns, any feeding
problems; age weaned from bottle or breast; type
of milk and daily intake; food preference; ability to
feed self.
• Development
– these are commonly used developmental
milestones.
– Parents may have baby books, which can
stimulate recall; photographs may be helpful.
– Age when able to:
• hold head erect while in sitting position,
• roll over from front to back and back to front,
• sit alone and unsupported,
• stand with support alone,
• walk with support alone,
• use words, talk in sentences, dress self.
– Age when toilet trained:
• approaches to and attitudes regarding toilet training.
– School:
• grade, performance, problems.
– Dentition:
• age of first teeth, loss of deciduous teeth, eruption of
first permanent teeth.
– Growth:
• height and weight in a sequence of ages; changes in
rates of growth or weight gain.
• Sexual:
– present status:
• in female, development of breasts, nipples, sexual hair,
menstruation (description of menses);
• in male, development of sexual hair, voice changes,
acne, nocturnal emissions.
• Illnesses:
– immunizations,
– communicable diseases,
– injuries,
– hospitalizations.
 Family History:
• Obtain a maternal gestational history,
– list all pregnancies together with the health status
of living children.
• For diseased children include date, age, cause
of death and dates and duration of
pregnancies in the case of miscarriages.
• Inquire about the mother’s health during
pregnancies and the ages of parents at the
birth of this child.
• Are parents cousins or otherwise related?
• A review of at least two generations on each
side of the family is desirable.
 Personal and social History.
• Personal status:
– school adjustment, masturbation, nail biting,
thumb sucking, breath holding, temper tantrums,
pica, rituals, bed wetting, constipation or fecal
soiling of pants, reactions to prior illnesses,
injuries or hospitalization.
• Home conditions:
– father’s and mother’s occupation,
– the principal caretakers of the child,
– parents divorced or separated,
– educational attainment of parents,
– cultural heritages;
– food prepared by whom,
– adequacy of clothing,
– dependence on relief or social agency,
– number of rooms in house and number of persons
in household;
– sleep habits, sleeping arrangements available for
the child.
• Review of Systems.
 Pregnant women.
Chief Complaint:
• The following information is included:
– patient’s age, marital status, gravidity and parity,
last menstrual period, previous usual menstrual
period, expected date of confinement/delivery,
occupation, and father of the baby and his
occupation.
 Present Problem:
• A description of the current pregnancy is
obtained and previous medical care is
identified.
• Attention is given to specific problems, e.g.
– nausea,
– vomiting,
– fatigue,
– edema.
 Obstetric History:
• Information on each pregnancy includes the
• date of delivery,
• length of pregnancy,
• weight and sex of infant,
• type of delivery
• spontaneous vaginal,
• cesarean section and type of scar- further documentation of
the scar is needed for women attempting vaginal birth after
cesarean section – or spontaneous or elective abortion),
• length of labor,
• complications in pregnancy or labor, postpartum, or
with the infant.
 Medical History:
• The same information as identified previously
is obtained, with the addition of risk factors
for AIDS, hepatitis, tuberculosis, and exposure
to environmental and occupational hazards.
• A mother who had intrauterine growth
restriction (IUGR) carries this risk factor for
her children.
 Family History:
• In addition to the information obtained
previously, a family history of genetic
conditions, twins, and/or congenital
anomalies is obtained.
 Personal and Social History
• Additional information includes
– feelings toward the pregnancy,
– whether the pregnancy was planned,
– preference for sex of child,
– social supports available,
– experiences with motherhood and history of
abuse in relationships.
 Review of Systems.
• Effects of pregnancy are seen in all systems,
but special attention is given to the
reproductive and cardiovascular systems.
 Risk assessment.
• Encompasses identifying from the history and
physical examination those conditions that
threaten the well-being of the mother and/or
fetus.
• Various risk categories exist such as
– diabetes,
– preterm labor,
– preeclampsia,
– eclampsia,
– pregnancy-induced hypertension.
Thank you