Goals & Objectives

History Taking

Chapter Goal Upon completion of this chapter, nurse will be able to use the appropriate techniques to obtain a medical history from a patient. Cognitive Objectives As anurse you should be able to do the following: Describe the techniques of history taking. Discuss the importance of using open and closed ended questions. Describe the use of facilitation, reflection, clarification, empathetic responses, confrontation, and interpretation. • Differentiate between facilitation, reflection, clarification, sympathetic responses, confrontation, and interpretation. • Describe the structure and purpose of a health history. • Describe how to obtain a health history. • List the components of a history of an adult patient.
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Affective Objectives As a nurse you should be able to do the following:
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Demonstrate the importance of empathy when obtaining a health history. Demonstrate the importance of confidentiality when obtaining a health history. .

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frequency) Setting in which symptoms occur Factors that aggravate or relieve Associated manifestations 2 . related symptoms Where: Location. Date. intensity. communicable exposure Why: Possible solutions. duration. age. Rx. duration & chronologic sequence of symptoms What: Quality. range of symptoms How: Associated factors. address. religion. PRESENT ILLNESS/PROBLEM: Or Current Health Status PI: Illness or focused history Initial wellness history Interval history PI: Analysis of a Symptom Onset Characteristics Course since onset • • • • • When: Last well: Onset. gender. HEALTH INSURANCE Referral source.HEALTH HISTORY FORMAT BIOGRAPHICAL DATA • • • Name. family/marital status. informant (reliability) (document) CHIEF COMPLAINT: Brief. occupation. 1-2 symptoms & duration. (aggravating/alleviating) ALTERNATIVE METHODS FOR PRESENT ILLNESS: PI PI: BATES • • • • • • • Location Quality Quantity of severity Timing (onset.

STD's. Hospital. date & # of units if known Emotional status: Mood disorders. psychiatric attention Any family members with patient's illness Age of parents: Age & cause of death if deceased Age & # of siblings: Health Status Hx of heart disease. drugs. Dx. sleeping. exercise. Must include "kind of" reaction Transfusions: Reactions. of stress • Habits: Diet. asthma. Complications • Injuries: • Resulting disability • Medical-legal relationships Medications: Current. past month.Treatment PAST MEDICAL HISTORY • • • • • • • • FAMILY HX General health & strength Major childhood & adult illnesses Immunizations & dates: reactions to immunizationsSurgery: Dates. socioeconomic group. general life satisfaction. alternative therapies Allergies: Meds. safety • Occupation: Work & conditions or hazards sources • • • • • 3 . tobacco • Sexual Hx: Satisfaction/concerns • Home conditions: Housing. TB. cancer. environmental.. past: Rx. thyroid disease Major genetic disorders & health problems: GENOGRAM TO GRANDPARENTS PERSONAL & PSYCHOSOCIAL HX • Personal status: Birthplace. coffee. kidney. interests. food. economic conditions.PI: OLD CART O – Onset L – Location D – Duration C – Causative factors A – Associations R – Reactions to what has been tried T . alcohol. & OTC. hypertension. herbs. diabetes.

sore tongue. sores. STDs 4 . pneumonia. fatigue. tenderness. SBE GENITOURINARY: Dysuria. sinus pain MOUTH & THROAT: Hoarseness. LMP. unexplained weight change. tinnitus. sexual activity. dyspnea. . leg pains/edema/coolness/hair loss. injury. exercise tolerance. thrombosis. color or texture changes. fertility. lesions/discharges. obstruction. cyanosis. TB/BCG. smoking CARDIOVASCULAR: Chest pain/distress. "swollen glands. heat/cold intolerance. duration. lumps. discharge. paroxysmal nocturnal dyspnea. emphysema. LOC. pain. bruising. hypertension. SOB. digestion intolerance. syncope. menopause. pain. discharge. blurring.• Environment: REVIEW OF SYSTEMS: ROS Travel. sexual activity. palpitations. . allergies. erections. hematomesis. GENERAL: Fever. pain. bowel irregularity. bleeding. STE FEMALE REPRODUCTIVE: Menses: Menarche. itching. injury. mammogram AND RESULTS. . preg. wheezing. sweats. eye meds. dental care." goiter. . stool appearance. ECG or other cardiac tests. sore throats. pain/stiffness LYMPH NODES: Enlargement. previous X-ray ENDOCRINE: Thyroid enlargement/tenderness. chills. jaundice. heat/cold intolerance. asthma. of flow. MI. last CXR & results. STDs. HAIR. dysmenorrhea. infection. antepartum problems BREAST: Pain. nocturia. diabetes S/S. RESPIRATORY: Pain. tenderness. urgency. testicular pain or masses. infertility. contraception. discharge. cataracts EARS: Hearing/loss. heartburn. flatulence\ . STDs Gravida/para: . orthopnea (pillows needed). rheumatic fever. duration & amt. ulcers GASTROINTESTINAL: Appetite. ulcer. edema. hematuria. sputum (color & quantity). taste NECK: Lumps. weakness. radiation SKIN. itching. abdominal enlargement. cough. glaucoma. last Pap AND RESULTS. redness. hernias. bronchitis. prostate. regularity. sores. NAILS: Rashes. weight changes. gallstones. varicose veins. lumps. gum problems. epistaxis. tooth abcess. dyspnea. SOB. frequency. N&V. diplopia. MALE REPRODUCTIVE: Puberty onset. stroke EYES: Vision/correction. vertigo/"dizziness" NOSE: Smell. galactorrhea. abnormal growths HEAD: Headaches. hemorrhoids. discharge. murmur. colds. trauma. hernias. dizziness. stress incontinence.

fatigue. irritability. transfusion. syncope. dizziness. tension. lymph swelling. weakness. paresthesias. radiation NEUROLOGIC: CNS disease. degenerative… • Pathophysiological – mal functioning. weakness/paralysis. such as congestive heart failure… • Psychopathological – behavioral. cognition. bruising/petechiae. or absence of abnormal findings PHYSICAL EXAMINATION • • • Inspection Palpation Percussion 5 . back problems HEMATOLOGIC: Anemia. motion restriction. mood changes. blackouts.MUSCULOSKELETAL: Joint stiffness. memory. tingling. deformities. thought process disturbance Construct a working hypothesis from the central findings Match the findings with all causative conditions you know could as associated Eliminate hypothesis that fail to explain the findings Weight the probabilities & select the most likely diagnosis Consider life-threatening & treatable situations Test the hypothesis or obtain further studies Establish a working definition of the problem • • • • • • • DOCUMENTAION OF DATA • • • Permanent medicolegal record of the patient’s health status & treatment Record pertinent postive findings – abnormal findings Record pertinent negative findings – normal findings. nervousness. numbness. metabolic. tremors coordination. cramps. mood disorder. sleep disturbances CONCLUDING QUESTIONS: "Is there anything else that you think would be important for me to know?" ANALYSIS OF DATA • • • • Identify abnormal findings Cluster findings into logical groups Localize findings anatomically Localize findings into probable process: • Pathological – such as inflammatory. headaches. blood . head injury PSYCHIATRIC: Depression. difficulty concentrating. pain. seizures. suicidal thoughts.

is discriminatory for temperature PERCUSSION SOUNDS HEARD • Tympany: • Hyperresonance: • Resonance: • Dullness: • Flattness: AUSCULATATION • • • Gastric bubble Emphysematous lung Healthy lung Liver Muscle Listening to sounds of lungs. Chest. heart. blood vessels & abdominal viscera Ear Stethoscope • Diaphram is held firmly to the skin. Extremities Temperature. Abdomen. Respiration & Blood Pressure Vison & hearing screening Jugular Venous Distention Body Mass Index Skin fold thickness 6 . Pulse. 1 cm or ½ to ¾ inches deep Deep palpation – may use bimanual methods. private conditions Provide adequate direct lighting PALPATION • • • • • • Light palpation – gentle pressure. is discriminatory for touch Dorsal area – of hand. detects low frequency sounds ANTHROPOMETRIC MEASUREMENTS & VITAL SIGN SELECTIONS: Will be discussed in the following section • • • • • • • • Height Weight Circumferences: Head. detects high frequency sounds • Bell is held with light pressure. 4 cms or 1.• • Auscultation Measurements INSPECTION • • • • • Observe for wellness – illness condition of the patient Identify degree of distress Look before you touch Provide comfortable.5 to 2 inches deep Palpate tender areas last Palmar area – of hand & fingers. is discriminatory for touch Ulnar area – of hand.

does the patient have a reason for secondary gain Essential Components of a Medical History 1 • Regardless of the event.g. including: 2 – Date 3 – Identifying data—age.• • Mid-upper arm circumfer Historical information often comes from a variety of sources. sex. spouse..): 1 – Immunizations 2 – Sleep patterns 3 – Exercise and leisure activities 4 – Environmental hazards 5 – Use of safety measures 6 – Family history Essential Components of a Medical History • Current health status (cont. and related substances–Diet 13 – Screening tests Essential Components of a Medical History • Current health status (cont.g.): 1 – Home situation (including pets. race 4 – Chief complaint (CC) 5 – History of the present illness (HPI) 6 – Past medical history (PMHx) 7 – Current health status 8 • Current health status includes: 9 – Current medications 10 – Allergies 11 – Tobacco use 12 – Alcohol. in a drug overdose or crime scene injury) 3 –Motivation (e.. including: 1 – The patient 2 – The family 3 – Friends 4 – Police officers 5 – Other observers • Factors that affect the quality of historical information include: 1 – Mental status (e..g. or significant others) 2 – Daily life 3 – Important experiences 4 – Religious beliefs 5 – Patient’s outlook on life overall 7 . drugs. the history must contain certain basic information. trust (e. possible intoxication) 2 – Memory.

it is difficult to remember all the details. obtaining all information on currenthealth status may not be possible or even appropriate. or tobacco Techniques of History Taking—Setting the Stage • Environment 1 – Proper environment enhances communication between you and the patient. especially when life-threatening problems arise. 4 – Respect the other person's personal space by not getting closer than 2 to 3 feet. during the initial interview. 7 – Many individuals are offended by the use of "sir" or "madam. and professional appearance will go a long way. and strength. 8 . 6 – Where possible.Essential Components of a Medical History—Current Health Status ← Depending on the circumstances. 3 – You may be more successful by placing the patient into the ambulance after a brief evaluation and continuing the interview there. 5 – Shaking hands is a good technique to calm the patient. including herbals and over-thecounter preparations) 4 – Use of drugs. address them and explain your reasons for taking notes to the patient. moisture. 12 – Do not divert your attention from the patient to take notes. neat." 8 • Note taking 9 – Especially in an uncontrolled situation. the patient and bystanders will be watching you. you should always strive to find a history of: 2 – Allergies 3 – Use of medications (with or without a prescription. 3 – The majority of our interpersonal communication occurs not by words. unless medically necessary. but rather by "body language. 1 • At a minimum. 11 – If concerns arise. Techniques of History Taking—Questioning Patients 1 • Ask open-ended questions whenever possible. the prehospital setting does not lend itself to an ideal history-taking atmosphere. 10 – Note taking is generally well accepted by patients and essential for proper documentation." 4 – A clean. 5 – Always treat people with respect regardless of the patient's presenting condition. refer to the patient by name. 2 – Often. Techniques of History Taking—Setting the Stage 1 • Your demeanor and appearance 2 – Just as you are watching the patient. as well as to initially evaluate skin temperature. alcohol.

" "Please continue. actions. it does not bias the story or interrupt the patient's train of thought.–Example: • "What I have heard so far is that you have a heaviness under your breast bone that started a half hour ago and that you have never had anything like it before—yes?" Techniques of History Taking—Questioning Patients •Clarification 1 – Interrupt or ask additional questions to clarify points. you said that breathing makes your pain worse.2 3 4 5 6 – "Tell me about the pain. you could ask an open-ended question: "Now." or "I am listening" to encourage the patient. when you breathe out. 0 – At this stage. a few short. 2 – It includes posture. directed questions may be appropriate. 5 – Avoid saying "I am listening" when you are obviously doing something else (e. 3 – Done properly. 1 • "Now." – "Do you have pain now?" – "Does it hurt you to breathe?" Techniques of History Taking—Questioning Patients • Facilitation 1 – This is a combination of verbal and nonverbal actions that we use to encourage the patient to say more. you said that breathing made your pain worse. . • Reflection 1 – This involves repeating the patient's words (or your summary of them) back to make certain you both are communicating. 4 – Use phrases such as "Go on. looking at equipment).. is this mostly when you breathe in. such as "yes" or "no. 3 – The most helpful method of facilitation often is often making eye contact. or words. or all the time?" 2 – Alternatively. 2 – It encourages additional responses by the patient.g." – "What things change your discomfort?" • Closed-ended or direct questions require a simple answer. when during your breathing is the pain made worse? 9 .

" 10 – Rarely. upper abdomen. 4 – Try to identify with what the patient is going through. simply saying something such as "Just do it!" is necessary for the best outcome.especially those that directly affect the current problem. let yourself try to relax some so I can help you out better. and empathetic. kind.. you suspect a possible heart attack. 3 – Though sympathy may be appropriate at some times. diabetes) or surgeries 11 – Medications 10 . 5 – Express to the patient things such as: ← "You sound uncomfortable. Techniques of History Taking—History of the Present Illness 1 • Factors that must be evaluated for any symptom include: 2 – Location 3 – Quality 4 – Quantity or severity 5 – Duration or timing 6 – Onset and setting 7 – Aggravating/alleviating factors 8 – Associated complaints 9 • Determine relevant factors in the patient's past medical history. 9 – Examples: ← "I'm here to help you—if I don't know what drugs you took. –Example: ← The patient complains of neck. I can't do you much good. 8 – It may be extremely helpful under selected circumstances. ← Verbally and with body language ← With your own knowledge and "gut feelings" 2 – Whether or not you share your interpretation with the patient depends on the circumstances." 6 • Confrontation 7 – It is more direct but potentially disruptive to your relationship with the patient.Techniques of History Taking—Questioning Patients 1 • Empathetic responses 2 – Empathy is very different from sympathy.g." ← "I'd probably be frightened if I were in your shoes. your job in history taking is to be professional. Techniques of History Taking—Questioning Patients • Interpretation 1 – Interpretation requires you to synthesize what the patient has told you. ← Based on answers to other questions. 10 – Preexisting medical problems (e." ← "I'm not any happier than you are that you hurt your leg. and left arm pain.

3 – Appear completely nonjudgmental. family physician) Family history Social history Techniques of History Taking—Past Medical History • Social history 1 – Housing environment 2 – Economic status 3 – Occupation 4 – High-risk behavior 5 – Travel history Techniques of History Taking—Current Health Status ← ← ← 1 2 3 4 5 6 7 Ask the patient about tobacco use.. 4 – Continually remind the patient that you are there to help. 1 • Consider the following to provide the best patient care possible: 2 – Always remain calm and professional. and other related substances. drugs.12 – 13 – 14 – 15 – Allergies Medical care (e. Note any special diet factors of interest.g. Determine the use of alcohol. • The "SAMPLE" acronym stands for: – S—Signs and symptoms – A—Allergies – M—Medications – P—Pertinent past medical history – L—Last oral intake. fluid or solid – E—Events leading to the present situation Techniques of History Taking—Standardized Approach to History Taking • The acronym "OPQRST" stands for: 1 – O—Onset 2 – P—Provocation 3 – Q—Quality 4 – R—Radiation–S—Severity 5 – T—Time Techniques of History Taking—Taking a History on Sensitive Topics ← Alcohol and drugs ← Physical abuse or violence ← Sexual history Techniques of History Taking—Taking a History on Sensitive Topics ← There is no "cookbook" way for a particular NURto deal with anyparticular patient. 11 .

Special Challenges—Silent Patient ← ← ← ← A silence is sometimes rather frustrating and confusing.5 – Don't be too reassuring.–Grimacing 2 – Touching or rubbing a particular area repeatedly 3 – Sweating–Crying ← Under emergency circumstances. Silence does not necessarily show that the patient is hostile. breathing. A silent patient often makes us feel uncomfortable. remember details. or uncooperative. 6 – Remember that the competent patient has the right to refuse to divulge information to you.problematic. Patients may use silence as a way to collect their thoughts. being talkative usually reflects that the patient is nervous and scared. after being certain that the patient can hear and understand you.) ← The best approach. 3 – Once you have ruled out immediate life-threats. or decide whether they trust you. Special Challenges—Anxious Patient 12 . Special Challenges—Silent Patient (cont. 1 • Be alert for nonverbal clues of distress. 1 • Possible ways to cope with the talkative patient while still maintaining a professional manner include: 2 – Lower your expectations 3 – Give the patient free reign for the first few minutes of the interview 4 – Summarize frequently 5 – Ask directed questions Special Challenges—Patients with Multiple Symptoms ← The trauma patient with many injury-related complaints ← The medical patient with multiple complaints 1 • The crucial point for both situations is that you must deal with appropriate priorities first 2 – Any disease or injury that threatens airway. enlist patients to help you rank their complaints. is patience. because over-assurance may hamper communication. or circulation (the ABC's) must be identified rapidly and cared for.

calm. to at least some extent. ← ← ← ← ← ← Special Challenges—Depressed Patient • Signs of depression include: 1 – Sad appearance–Crying 2 – Inappropriate responses. the patient may displace anger toward you. with minimal stimuli 3 – Sleep disturbance 4 – Abnormal appetite (decreased or increased) 5 – Suicidal actions ← Special Challenges—Patient with Confusing Behavior or History ← Consider confusing or unusual behavior to be the result of a potentially serious medical problem until proven otherwise. ← Avoid telling the patient things like "everything's all right. get appropriate assistance immediately. Special Challenges—Crying Patient Crying may be the result of many factors. and acknowledge it. Use a gentle. especially crying. You must remain calm in your response to the patient. including pain and fear. If there are perceived physical dangers.← ← ← 0 1 ← ← ← ← ← ← ← Everyone is usually anxious. The best way to deal with a crying patient may be to simply offer tissue paper. Sometimes. Remain objective and empathetic. Use caution with reassurance." ← Realize that the patient feels bad. Crying is expected in many children but occurs in adults as well. Much of the time. 13 . Although you are there to help. such as illness or injury. Depression ranges in severity from a temporary response to a situation to a severe psychiatric illness that may result in violent behavior." or "things will work out. Do not place yourself in or allow yourself to remain in a potentially volatile situation. this is not done purposefully or with any bad intent. and professional approach. Anger and hostility are normal reactions to undesirable circumstances. ← A thorough history from bystanders and the patient can assist in narrowing in on the cause. people talk fast as a response. • Remember that much human communication is performed by nonverbal means. Others talk much slower or even become silent. – Pay close attention to these nonverbal clues. when sick or injured. ← Remain sympathetic and professional with the patient. especially while attempting to identify the cause of the patient's behavior. ← Acceptance of the situation with empathy is the best communication technique.

← Get additional information from family or friends. ← Speak clearly. 14 .Special Challenges—Patient with Limited Intelligence ← Even patients with limited intellectual capacity can express their basic needs. and symptoms if given a chance. direct your interview toward them first. feelings. ← Expect to take more time than usual for the patient to respond to your question. ← If patients are capable of communicating. but normally. ← Remember to be patient and professional.

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otherwise well.M. Four years ago Mr. one sister. Kevin. Dorothy. well No family history of diabetes. Arthur. finished high school. with hypertension. Dorothy’s husband. eats dinner alone. Mrs. had varicose veins. Children all married. N died suddenly of a heart attack. son. with headaches. son. or mental illness. N feels responsible for helping them. then moved with husband to Amarillo. 3 years. N has moved to small apartment to be near daughter. tuberculosis. Mother died at age 67 of stroke. 31. Mrs. married at age 19. with migraine headaches. one brother. feels tense and nervous but denies depression. She is typically up at 7:00 A. 33. otherwise well.. leaving little savings. heart or kidney disease. works 9:00 to 5:30. had 3 children. Personal and Social History: Born and raised in Lake City.” No church or other organizational support. and Linda. well except for mild arthritis. 58. Mrs. died in infancy of unknown cause Husband died at age 54 of heart attack Daughter. N’s apartment now a haven for Dorothy and her 2 children. 6 years. Worked as sales clerk for 2 years. 61. 27. anemia. has an alcohol problem. Returned to work 15 years ago because of financial pressures. cancer. headaches One brother.father died at age 43 in train accident. I don’t like gossip. epilepsy. She has friends but rarely discusses family problems: “I’d rather keep them to myself. 18 .

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