HISTORY

TAKING
 Aim

• Obtain data 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
• Beginning of nurse – patient relationship.

• Put the patient at ease and encourage him to

talk freely.

• Be friendly, say who you are and your role.

• Establish eye contact.

• 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?

• If you are a student do not hide it.

• Pronounce patient’s name 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 pa-

tient, 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 in-

formation is sought and how it will be used
 Sensitive issues
• Not easy to question a patient on sensitive is-
sues like sex.

• 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.

• Do not be judgmental.
• Use language that is understandable to client.

• Do not push too hard.

• If the patient is defensive, recognize that the

patient feels that defense is necessary.
OUTLINE OF CLINICAL HISTORY: BODY SYSTEMS
MODEL
Biographical data
• Personal details of patient

• Includes
– Name, Address, Age, Gender, Marital status, Oc-
cupation,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?”

• Determine duration of the illness.

 History of Presenting Illness
• Details of the current problem(analysis of s/s)

• Recorded in chronological order from onset to

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.
• Describing how problem started (Onset)
– Date and manner (sudden or gradual)
– 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 treat-
ment, 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 to identify risk factors that stem from

previous health problems

• Includes
– General health status.
– Childhood illnesses e.g. measles
– Major adult illnesses: tuberculosis, hepatitis, dia-
betes, hypertension, heart diseases.

– Immunization status: polio, diphtheria, pertussis,

tetanua toxoid, influenza, cholera, typhus, bacilli
Calmette-Guerin(BCG) etc.

– Surgery and hospitalization: dates, hospital, diag-

nosis, complications.
– Serious injuries resulting to disability.

– Limitation of ability to function as a result of past

events.

– Medications: past, current and recent medications

– Allergies

– Transfusions: reactions, date, number of units.

– 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 emo-
tional or mental problems?
• If so, please describe their nature and any treatment
received.
• Describe your level of satisfaction with the treatment.”
 Family History

• Blood relatives in the family who have ill-

nesses with features similar to the patient’s
illness.

• Ethnicity, health, or cause of death of parents

and siblings, including their ages at death.
• Hereditary disease such as sickle cell disease
– History of grandparents, aunts, uncles, siblings
and cousins concerning hereditary diseases.

• History of familial disease like heart disease,

high blood pressure, cancer, tuberculosis,
stroke.
 Personal and Social History

• Personal status
– Birthplace, where raised, home environment, so-
cioeconomic class, cultural background, educa-
tion, position in family, marital status, general life
satisfaction, hobbies, interests, sources of stress,
strain.
• Habits
– Nutrition and diet, regularity and patterns of eat-
ing and sleeping, exercise, alcohol, illicit
drugs(frequency, type and amount), quantity of
tea, coffee, tobacco, breast or testicular self exam-
ination.
• 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 dif-
ferent
– list of job changes
– work conditions and hours
– duration of employment

• Religious preferences
– Any religious proscriptions concerning medical
care.
 Others

• Developmental history
 Review of Systems

• All major systems are reviewed

• Ask 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.
– General
• weight, sleep, energy

– GIT, abdomen and pelvis

• pain, appetite, vomiting, general characteristics of vom-
ited matter, flatulence, heartburn, dysphagia, diar-
rhoea, 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.

• Include child as appropriate for his/her age.

• 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 as-
sume 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, bleed-
ing.

– Medications, hormones, vitamins, special or un-

usual 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 anes-
thesia, 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 characteris-
tics, vigor, cry;

– Duration of baby’s stay in hospital

– Bilirubin phototherapy, prescriptions

– 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
• 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 prob-
lems; age weaned from bottle or breast; type of
milk and daily intake; food preference; ability to
feed self.
• Development
– 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 sta-
tus of living children.

• For diseased children include date, age, cause

of death and dates and duration of pregnan-
cies in the case of miscarriages.
• Mother’s health during pregnancies and the
ages of parents at the birth of this child.

• Are parents 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 soil-
ing 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 occupa-
tion.
 Present Problem

• A description of the current pregnancy and

previous medical care.

• Attention is given to specific problems, e.g.

– nausea, vomiting, fatigue, edema.
 Obstetric History

• Information on each pregnancy includes

• date of delivery, length of pregnancy, weight and
sex of infant, type of delivery (spontaneous vagi-
nal, cesarean section and type of scar), length of
labor, complications in pregnancy or labor, post-
partum, 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 restric-

tion (IUGR) carries this risk factor for her chil-
dren.
 Family History

• In addition to the information obtained previ-

ously, a family history of genetic conditions,
twins, and/or congenital anomalies is ob-
tained.
 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 reproduc-
tive 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.

• Examples of risks: diabetes, preterm labor,

preeclampsia, eclampsia, pregnancy-induced
hypertension.
 FUNCTIONAL HEALTH PATTTERNS APPROACH
TO HISTORY TAKING
• Handout
Thank you