HistoryTaking.pdf well prepared and grammatically

History taking from nursing school students

1. History Taking
P. KATETE

2. Learning Outcomes
Define health history
Explain three types of health history
Explain the purpose of taking health history
Explain the importance of health history taking
Describe the good interviewing skills
Explain the components of health history

3. Definition
History taking is the collection of subjective information on the patient’s
health status from the well client or ill patient and from other sources.
A data collection about the client’s current level of wellness including a
review of body systems, family and health history, social cultural history,
spiritual health and mental and emotional reaction to illness (Potter &
Perry, 2005, p. 289)

4. Description
Data collection includes the gathering of subjective and objective data.
◦Subjective data are clients’ perceptions about their health problems. clients
or significant others e. guardian can provide this kind of information.
◦Objective data, are observations or measurements made by the data
collector.

5. Sources of Data
Family members and significant others
Medical records
Stranger in case of severe accident

6. Types of Health History
Complete health history
Interval health history
Problem focused health history

7. Types of Health History
Complete health history
◦This type of health history is taken on an initial visit to health care facility
when the providers within the facilities will be providing comprehensive and
continuous care. This type of history includes history of present illness,
review of systems, past medical, surgical, family, social history

8. Types of Health History
Interval health history
◦This is used to collect information in visits following the one in which an
initial data base is collected. E.g. use of health passport books. It includes a
detailed history of present illness i.e. location, Quality, Severity, Duration. It
also includes review of systems Take note that this type of history does not
include past medical, surgical, family, social history

9. Types of Health History
Problem focused health history
This type of history is used to collect data about a specific problem on a
system or a region
It is the lowest and least descriptive level of history.This
historyrequires only a chief complaintand abrief history of present
illness. It Also includes review of the system of the affected part

10. Purpose of Health History
To provide subjective data base
Identify client strengths and weaknesses
Identify client health problems, both actual and potential
Identify patterns of health and illness
Identify risk factors for physical and behavioral health problems
To establish a trusting and supportive relationship

11. Purpose of Health History
Identify support
Identify teaching needs
Identify discharge needs
Identify deviations from normal and available resources for adaptation
Identify referral needs

12. Group Activity
In groups of 4
Discuss how you can prepare for a history taking session
Discuss the skills that are required during history taking ( use your
previous knowledge from language and communication module)

13. Importance of Health History
Assists in development of nurse-patient relationship and build trust on
each other
Enables the nurse to develop a complete plan of care
Serves as a foundation for physical and laboratory data as it directs the
examiner towards the system to be examined intensively

14. Importance of Health History
It gives a clear picture of the patients and his health problems
When clearly recorded, it eliminates the tendency for repetitions
interviews hence time spent with the patient is used more efficiently
thereby enhancing inter disciplinary approach to health care
For legal purposes

15. Approach to History Taking
Good Interviewing Skills
◦Non verbal communication
◦Facilitation
◦Reflection
◦Paraphrasing
◦Clarification
◦Summarization
◦Validation
◦Empathic responses
◦Transition

16. Components of a Health
History
Biographical information:
This provides initial insight into the client as a unique person and can
be correlated with the client’s needs and problems. This includes
◦Name, date of birth (age), address, religion, sex, marital status, occupation,
level of education, next of kin

17. Components of a Health
History
Chief complaint:
◦This is a brief statement of the reason the patient is seeking care
Why have you been admitted to the hospital today?
Why have you come to the health centre today?
Record patients exact words
Sometimes no chief complaint –people just come for a check-up

18. Components of a Health
History
History of present illness:
◦This is a step by step evaluation of the circumstances that surround the
primary reason for the patient’s visit. It isused to describe the status of the
symptoms or clinical problems from time of onset or since the previous
encounter with the physician

19. Components of a Health
History
History of present illness ct..
◦It includes the following elements:
Onset
◦Location
◦Quality
◦Severity
◦Duration
◦Timing
◦Context
◦Modifying Factors
◦Associated Signs and Symptoms

20. Components of a Health
History
Example of History of present illness:
◦Patient complains of chest pain (location), which began three hours ago
(duration).Pain has been off and on since that time with each episode
lasting two to three minutes (timing).The pain is described as “crushing”
(quality) and at times is rated as an eight on a scale of one to ten
(severity).The pain occurs with minimal exertion (context) and is associated
with nausea and shortness of breath (associated signs and symptoms).The
pain was relieved with sublingual NTG in the ambulance (modifying factors).

21. Components of a Health
History
Past medical history:
A review of past illnesses, or injuries, which may include
◦Prior illnesses
◦Prior hospitalizations
◦Current medications
◦Allergies
◦This assist to identify client’s past major health problems.

22. Components of a Health
History
Past medical history Ct..
Diabetes, Hypertension, TB,, epilepsy, cardiac disease, asthma, mental
illness, STI, anaemia, HIV and AIDS

23. Components of a Health
History
Past surgical history:
A review of past operations or injuries, which may include
◦Prior injuries
◦Prior operations, type e.g. lapalatomy, pelvic trauma
◦Prior hospitalizations
◦This assist to identify client’s past major surgical health problems.

24. Components of a Health
History
Past Obstetric history
◦Breakdown of deliveries
◦Mode of deliveries
◦Complications
◦Gynecological problems
◦Discharge: itchy, odour, colour, amount, consistency
◦Warts
◦Sores

25. Components of a Health
History
Nutrition History
◦Pica
◦vomiting
◦24 hour dietary profile and eating habits
◦Food preparation
◦Food availability and storage
◦Sources of water
◦Cultural. Religious food restrictions

26. Components of a Health
History
Psychological history
◦Planned/ unplanned pregnancy
◦Acceptance of the pregnancy by woman, partner
◦Domestic violence
Family planning history
◦Method used and reason for discontinuation
◦Reproductive health goals

27. Components of a Health
History
Sexual History
◦Problems associated with sexual intercourse
◦Cultural practices related to sex

28. Components of a Health
History
Family history:
A review of medical events in the patient’s familywhich mayinclude
information about:
◦The health status or cause of death of parents, siblings and children
◦Specific diseases related to problems identified in the Chief Compliant,
history of present illness, or review of system

29. Components of a Health
History
Family History Ct..
◦Diseases or conditions of family members which may be hereditary or place
the patient at risk e.g. diabetes, hypertension, twins, asthma, TB, epilepsy,
mental illness
The purpose is to learn about general health of the client’s blood
relatives, spouse and children.

30. Family Health History
•You are asking about first order relatives (parents, siblings, spouse,
children)
•Second order relatives (grandparents, cousins, aunts and uncles)
•WHY?
•Identify disease that are hereditary, communicable or environmental
in cause
•Cancer, hypertension, heart disease, diabetes, epilepsy, mental illness,
tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism,
obesity
•One of the easiest ways to record can be by drawing a family tree.

31. 70 lung
cancer
90 heat
disease
78 Stroke
82 Ca
Colon
60 Ca
Breast
Alzheimer'
s
62
Diabetes
32 AIDS
30 36
Hypertension
3 A + W
5
A+W
8
Asthma
Key
Male
Female
Deceased
A+W Alive and Well
Patient

32. Components of a Health
History
Social history
An age appropriate review of the patient’s past and current activities
which may include significant information about:
◦Marital status and/or living arrangements
◦Current employment
◦Occupational history
◦Use of drugs, alcohol or tobacco
◦Level of education
◦Sexual history
◦Income generating activities and support system

33. Components of a Health
History
Usual health status: try to elicit a sense of the client’s perception of or
feeling about his or her health over the past year

34. Review of Systems
Integumentary
Head and Neck
Eyes
Ears
Nose and Sinuses
Mouth and Throat
Respiratory system
Cardiovascular

35. Activities of daily living
Is patient able to perform all the activities of daily living.

36. Review of Systems
•Can be called the body system model or medical model
•Focus is on patients major anatomic systems
•You collect data on past and present condition for each organ or body
system
•Looking for actual or potential problems.
•Often reveals information the patient left out as they considered it
–Not important
–Forgot about it

37. What systems should be
reviewed
•General health state
•Neurologic
•Cardiovascular
•Respiratory
•Gastrointestinal
•Genito-urinary
•Musclo-skeletal
•Integumentary

38. General Health Status
•How would the patient describe their state of health normally?
•What has now changed?
•What can’t they do now compared to their normal level of functioning?
•You are assessing their activities of daily living (ADLs) some of which will
be incorporated within the different systems you are reviewing
•Including nutritional assessment (this is covered in detail later in the
course)

39. Neurological assessment
•Sensation
•Balance
•Walking
•Memory
•Conscious level
•Smell
•Vision
•Hearing
•Mood
•Fits / seizures

40. Cardiac Assessment
Ask the patient about any signs of cardiac disease –these include
dizziness, shortness of breath, pain, palpitations, cough, swelling in the
legs, calf or leg pain, fluttering in the heart, fatigue.
How has this problem limited their activities
How long have they had this problem for

41. Respiratory Assessment
Respiratory history should focus on four major areas
◦Risk factors for lung disease
◦Smoking, occupational exposure to pollutants
◦Signs and symptoms of respiratory distress
◦Cough, sputum production, dyspnoea

42. cont
◦Impact of respiratory status on the ADLs
◦How far can they walk, can they talk in
whole sentences
◦Adaptive measures the patient takes
◦Stopping to rest when walking, sitting
down when doing certain activities

43. Gastrointestinal system
•What areas does this cover?
•What is their normal bowel function and are they experiencing any
difficulties?
–How often do you have your bowels open
–What is the texture like
–Is there any pain on defecation
–When did you last have your bowels open
–What was it like
–Are you passing any gas either orally or rectally

44. Any difficulties in eating?
◦If the answer is yes then you need to explore this more
Any difficulties in swallowing?
◦If the answer is yes then you need to explore this more.

45. Genitourinary system
All patients
◦Any difficulty in passing urine
◦Pain, hesitancy, flow rate, feeling of not emptying bladder fully, frequency of micturition,
burning sensation,
◦What colour is your urine usually
◦Blood in urine
◦Has there been any change
◦Any history of sexually transmitted diseases

46. Genitourinary cont
•Female patients
–What age were you when you began menstruating, typical menstrual cycle,
any problems related to menstrual cycle, how many times have you been
pregnant, how many children do you have.
•Male patients
–Do you examine your testicles? How often?
–Do you have any concerns about sexual function?

47. Musculo-skeletal system
Joint mobility
Muscle strength
History of broken bones
Pain on movement
Difficulty in moving

48. Integumentary system
•Assessing skin, hair and nails
•Questions you could ask
–What is your usual daily skin care regimen
–Same for hair
–Do you suffer from any skin conditions
–Have you any tattoos, birthmarks, moles, freckles
–Have you had any hair loss or change
–What do you use to protect your skin from the sun
–Any scars or wounds?
–Any problems with your nails?

49. Review of Systems
Integumentary-no diaphoresis or skin rashes
Head and Neck –denies having sores or swollen neck lymph nodes
Eyes –denies any eye discharges or visual problems
Ears -Denies any discharges
Nose and Sinuses –denies any abnormal discharges
Mouth and Throat –No trouble swallowing,
Respiratory system –Denies shortness of breathe or cough
Cardiovascular –no chest pain

50. Review of Systems
Breasts -no sores or lumps
Gastrointestinal –denies heart burn or indigestion
Genitourinary –denies painful micturition
Female reproductive –denies genital ulcers normal menstrual cycle
Male reproductive –denies presence of any genital ulcers
Musculoskeletal –denies musculoskeletal pain
Neurological -no stroke, no dysphagia
Endocrine –no goitre
Hematologic –denies any history of low HB

51. General Health Survey
General health survey
◦This includes clients general state of health. This general survey continues
throughout the history and examination
◦Watch the client’s facial expression and note manner, reaction to people and
things. Listen to the manner of speaking and note the state of awareness or
level of consciousness

52. REFERENCES
Barkauskas, V. H, Baumann, L.C., Darling Fisher, C.S (2003).Health and
physical assessment. (3rd Ed.). Philadelphia: Mosby.
Estes, M.E.Z. and Buck, M. (2007). Health assessment and physical
examination. Toronto: Thomson Nelson.
Potter, A. & Perry, A. G. (2005). Fundamentals of nursing (6th Ed.) St.
Louis: Elsevier.

53. Activity
Read more on components of health history from the references of this
unit
In your groups discuss on the details of the components of a health
history
Read about recording health history
Role play history taking with your colleagues
Record your findings from the role play you have had and present them
to your lecturer
Analyze a role pay on history taking

54. Any Question?
Thank you