History Taking 1.1.pptx

Improve your History Taking skills at work and as a student

1. HISTORY TAKING SAPHAN C. AGABA BScN, MSc. HPE UGANDA CHRISTIAN UNIVERSIT Y

2. INTRODUCTION History taking skills are an essential component in a nursing curriculum and practice Forms the base for reaching a correct diagnosis

3. Definition A patient narrative facilitated by a health professional to obtain specific information about the patient to aid in formulating a diagnosis and decision making

4. KEY PRINCIPLES IN HISTORY TAKING Always listen to the patient Privacy and confidentiality loosen up the patient 80% of the diagnoses are through history taking alone Always use a systematic approach Never forget IPC protocols Rapport is significant. You are not a robot Patient comfort (physical and emotional) is critical Patient has rights Summarize each stage of History before the next Clear, legible and accurate documentation

5. First Impression “ You never get a second chance to make a first impression ”- unkown MAKE A POSITIVE FIRST IMPRESSION Appearance Body language Confidence Demeanor

6. STADARD FORMAT FOR HISTORY TAKING Bio-data Presenting/chief complaint History of Presenting complaint History of past illnesses –medical & Surgical. 5. Drug/ Medication History 6. Family History 8. Social History 9. Review of systems

7. 1. Bio-data Name Age & DOB Address Sex Tribe Religion Occupation Next of kin Contact information Who gave the information (Primary Vs Secondary source)

8. 2. Chief complaint The single most critical concern to the patient What brings you to the hospital today? What seem to bother you today? Critical Thinking? Have I clearly understood the patient’s chief complaint? What system could be affected? Patient uses his own words to describe their reason for visiting the hospital Record this complaint with its onset and duration If patient has many complaints, you can ask… If I could make one thing better for you today, what would it be?

9. 3. HISTORY OF PRESENTING COMPLAINT(s) SYMPTOM ANALYSIS Details of the current complaint are expounded further. How does the complaint affect Activities of daily living SOCRATES Site-Onset-Character-Radiation-Associated symptoms-Timing-Exacerbating factors-Severity PQRST OLDCARTS

10. Symptom Analysis Cont’d

11. Pain assessment for young children

12. Sample Hx of PI Patient reports having been well at least 2 days before admission when the patient fell off a motorcycle and injured his right foot . 3 hours after the incident, the foot got swollen and patient couldn’t step on his right foot . On the same day, the patient attended the nearby clinic where he received an injection unknown to him to relieve the pain. However, patient reports no improvement was realized.(dose) but doesn’t feel this pain anywhere else.

13. 4. Past medical history Past Illnesses Any chronic illness Hospitalizations Operations Any past illnesses that could be related to today’s complain Any history of similar complaints in the past? Any allergies?

14. 5. Medication History Current prescriptions and any other for longstanding illness An accurate medication history provides a foundation for assessing the appropriateness of a patient’s current therapy and directing future treatment choices.

15. 6. FAMILY HISTORY Some illnesses are familial while others are genetic Parents and siblings suffer from the same? For example: Patient with anemia, does anyone else at home experience these symptoms ??? Sickle cell Anemia?

16. 7. Social History Smoking History: Type, amount, Frequency, duration Alcohol use: Type, amount, Frequency, duration Any addictions? Sexual History Risk for Occupational hazards?

17. 8. REVIEW OF SYSTEMS. Main Points SYSTEM GUIDING SAMPLE QUESTIONS General health How do you feel compared to normal? How is your appetite? Have you lost/gained weight? Do you feel more tired than normal? Respiratory ( Resp ) Any breathlessness? Colds, coughs, wheezing? Sputum? Colour ? Cardiovascular (CVS) Any chest pain or breathlessness? Palpitations or dizziness? Any oedema ? Nervous system (CNS) Any headaches or visual disturbance? Numbness or tingling? Any fits? Balance problems? Tremors? Any (new) speech or hearing problems? Gastrointestinal (GI) Any episodes of D&V? Any abdominal pain? Any change in bowel habit, or blood in stool? Weight loss/gain

18. 8. REVIEW OF SYSTEMS. Main Points SYSTEM GUIDING SAMPLE QUESTIONS Genitourinary (GU) Any change in frequency of urination? Burning or stinging sensation? Blood in urine? Discharge? Last menstrual period? Any risk of pregnancy? Any unprotected sexual contact? (If appropriate to ask) Bones/muscles/joints (BMJ) Any new joint pain? Any stiffness or aching? Decreased mobility? Other Endocrine problems —excessive thirst, sweating? Intolerance to heat or cold? Bleeding or bruising? Rashes? Any swollen lymph nodes? Note: This is not an exhaustive list

19. CONCLUDE THE HISTORY TAKING EXERCISE Give a summary to the patient Ask/check if you understood the information correctly Any other information you would like me to know? Ask the patient Advise on what the plan will be or next step Involve patient in planning

20. Common Pit falls Difficult patient Using a tone of voice that sends a wrong message.. What is your problem today, why did you come here today? Poor choice of words – Using jargons