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.

Affective Objectives
As a nurse you should be able to do the following:

• Demonstrate the importance of empathy when obtaining a health history.

• Demonstrate the importance of confidentiality when obtaining a health history.

• .

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HEALTH HISTORY FORMAT

BIOGRAPHICAL DATA

• Name, age, gender, family/marital status, religion,

• Date, address, occupation, HEALTH INSURANCE
• Referral source, informant (reliability) (document)

CHIEF COMPLAINT: Brief, 1-2 symptoms & duration,

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, duration & chronologic sequence of symptoms

• What: Quality, intensity, related symptoms
• Where: Location, range of symptoms
• How: Associated factors, communicable exposure
• Why: Possible solutions, Rx, (aggravating/alleviating)

ALTERNATIVE METHODS FOR PRESENT ILLNESS: PI

PI: BATES

• Location
• Quality
• Quantity of severity
• Timing (onset, duration, frequency)
• Setting in which symptoms occur
• Factors that aggravate or relieve
• Associated manifestations

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PI: OLD CART

O – Onset
L – Location
D – Duration

C – Causative factors
A – Associations
R – Reactions to what has been tried
T - Treatment

PAST MEDICAL HISTORY

• General health & strength

• Major childhood & adult illnesses
• Immunizations & dates: reactions to immunizations-
• Surgery: Dates, Hospital, Dx., Complications
• Injuries:
• Resulting disability
• Medical-legal relationships
• Medications: Current, past month, past: Rx. & OTC, herbs, alternative therapies
• Allergies: Meds, environmental, food. Must include "kind of" reaction
• Transfusions: Reactions, date & # of units if known
• Emotional status: Mood disorders, psychiatric attention

FAMILY HX

•
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, hypertension, cancer, TB, diabetes, asthma, STD's, kidney, thyroid disease
•
Major genetic disorders & health problems:
GENOGRAM TO GRANDPARENTS
PERSONAL & PSYCHOSOCIAL HX

• Personal status: Birthplace, socioeconomic group, general life satisfaction, interests, sources
of stress
• Habits: Diet, sleeping, exercise, coffee, alcohol, drugs, tobacco
• Sexual Hx: Satisfaction/concerns
• Home conditions: Housing, economic conditions, safety
• Occupation: Work & conditions or hazards

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 • Environment: Travel,
REVIEW OF SYSTEMS: ROS

GENERAL: Fever, chills, sweats, weight changes, weakness, fatigue, heat/cold intolerance, bleeding, radiation

SKIN, HAIR, NAILS: Rashes, lumps, sores, itching, color or texture changes, bruising, abnormal growths

HEAD: Headaches, injury, dizziness, syncope, LOC, stroke

EYES: Vision/correction, blurring, diplopia, eye meds, trauma, redness, pain, glaucoma, cataracts

EARS: Hearing/loss, pain, discharge, infection, tinnitus, vertigo/"dizziness"

NOSE: Smell, obstruction, injury, epistaxis, discharge, colds, allergies, sinus pain

MOUTH & THROAT: Hoarseness, sore throats, gum problems, tooth abcess, dental care, sore tongue, taste

NECK: Lumps, "swollen glands," goiter, pain/stiffness

LYMPH NODES: Enlargement, tenderness,

RESPIRATORY: Pain, dyspnea, SOB, cyanosis, wheezing, cough, sputum (color & quantity), asthma,
bronchitis, emphysema, pneumonia, TB/BCG, last CXR & results, smoking

CARDIOVASCULAR: Chest pain/distress, palpitations, SOB, dyspnea, orthopnea (pillows needed),

paroxysmal nocturnal dyspnea, MI, rheumatic fever, murmur, exercise tolerance, ECG or other cardiac
tests, hypertension, edema, leg pains/edema/coolness/hair loss, varicose veins, thrombosis, ulcers

GASTROINTESTINAL: Appetite, digestion intolerance, heartburn, N&V, hematomesis, bowel irregularity,

stool appearance, flatulence\ , hemorrhoids, jaundice, ulcer, gallstones, abdominal enlargement,
previous X-ray

ENDOCRINE: Thyroid enlargement/tenderness, heat/cold intolerance, unexplained weight change, diabetes

S/S,

MALE REPRODUCTIVE: Puberty onset, erections, , testicular pain or masses, hernias, lesions/discharges, ,
sexual activity, , infertility, prostate, STDs, STE

FEMALE REPRODUCTIVE: Menses: Menarche, regularity, duration & amt. of flow, dysmenorrhea, LMP,
last Pap AND RESULTS, sexual activity, , contraception, fertility, menopause, discharge, itching,
sores, STDs
Gravida/para: , preg. duration, antepartum problems

BREAST: Pain, tenderness, discharge, lumps, galactorrhea, mammogram AND RESULTS, SBE

GENITOURINARY: Dysuria, pain, frequency, urgency, nocturia, hematuria, stress incontinence, hernias,
STDs
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MUSCULOSKELETAL: Joint stiffness, pain, motion restriction, weakness, paresthesias, cramps, deformities,
back problems

HEMATOLOGIC: Anemia, lymph swelling, bruising/petechiae, fatigue, blood , transfusion, radiation

NEUROLOGIC: CNS disease, syncope, blackouts, dizziness, numbness, tingling, seizures, weakness/paralysis,
tremors coordination, memory, cognition, headaches, head injury

PSYCHIATRIC: Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts,
irritability, 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, metabolic, degenerative…
• Pathophysiological – mal functioning, such as congestive heart failure…
• Psychopathological – behavioral, mood disorder, 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, or absence of abnormal findings

PHYSICAL EXAMINATION

• Inspection
• Palpation
• Percussion
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 • Auscultation
• Measurements

INSPECTION

• Observe for wellness – illness condition of the patient

• Identify degree of distress
• Look before you touch
• Provide comfortable, private conditions
• Provide adequate direct lighting

PALPATION

• Light palpation – gentle pressure, 1 cm or ½ to ¾ inches deep

• Deep palpation – may use bimanual methods, 4 cms or 1.5 to 2 inches deep
• Palpate tender areas last
• Palmar area – of hand & fingers, is discriminatory for touch
• Ulnar area – of hand, is discriminatory for touch
• Dorsal area – of hand, is discriminatory for temperature

PERCUSSION SOUNDS HEARD

• Tympany: Gastric bubble

• Hyperresonance: Emphysematous lung
• Resonance: Healthy lung
• Dullness: Liver
• Flattness: Muscle
AUSCULATATION

• Listening to sounds of lungs, heart, blood vessels & abdominal viscera

• Ear
• Stethoscope
• Diaphram is held firmly to the skin, detects high frequency sounds
• Bell is held with light pressure, detects low frequency sounds
ANTHROPOMETRIC MEASUREMENTS & VITAL SIGN SELECTIONS:
Will be discussed in the following section

• Height
• Weight
• Circumferences: Head, Chest, Abdomen, Extremities
• Temperature, Pulse, Respiration & Blood Pressure
• Vison & hearing screening
• Jugular Venous Distention
• Body Mass Index
• Skin fold thickness
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 • Mid-upper arm circumfer

•Historical information often comes from a variety of sources, 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., possible intoxication)
2 – Memory, trust (e.g., in a drug overdose or crime scene injury)
3 –Motivation (e.g., does the patient have a reason for secondary gain
Essential Components of a Medical History
1 • Regardless of the event, the history must contain certain basic information,
including:
2 – Date
3 – Identifying data—age, sex, 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, drugs, and related substances–Diet
13 – Screening tests
Essential Components of a Medical History
• Current health status (cont.):
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.):
1 – Home situation (including pets, spouse, or significant others)
2 – Daily life
3 – Important experiences
4 – Religious beliefs
5 – Patient’s outlook on life overall

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 Essential Components of a Medical History—Current Health Status
← Depending on the circumstances, obtaining all information on currenthealth status
may not be possible or even appropriate.
1 • At a minimum, you should always strive to find a history of:
2 – Allergies
3 – Use of medications (with or without a prescription; including herbals and over-the-
counter preparations)
4 – Use of drugs, alcohol, or tobacco

Techniques of History Taking—Setting the Stage

• Environment
1 – Proper environment enhances communication between you and the patient.
2 – Often, the prehospital setting does not lend itself to an ideal history-taking
atmosphere.
3 – You may be more successful by placing the patient into the ambulance after a brief
evaluation and continuing the interview there.
4 – Respect the other person's personal space by not getting closer than 2 to 3 feet,
unless medically necessary, during the initial interview.
5 – Shaking hands is a good technique to calm the patient, as well as to initially
evaluate skin temperature, moisture, and strength.

Techniques of History Taking—Setting the Stage

1 • Your demeanor and appearance
2 – Just as you are watching the patient, the patient and bystanders will be watching
you.
3 – The majority of our interpersonal communication occurs not by words, but rather
by "body language."
4 – A clean, neat, and professional appearance will go a long way.
5 – Always treat people with respect regardless of the patient's presenting condition.
6 – Where possible, refer to the patient by name.
7 – Many individuals are offended by the use of "sir" or "madam."
8 • Note taking
9 – Especially in an uncontrolled situation, it is difficult to remember all the details.
10 – Note taking is generally well accepted by patients and essential for proper
documentation.
11 – If concerns arise, address them and explain your reasons for taking notes to the
patient.
12 – Do not divert your attention from the patient to take notes, especially when
life-threatening problems arise.
Techniques of History Taking—Questioning Patients
1 • Ask open-ended questions whenever possible.
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2 – "Tell me about the pain."
3 – "What things change your discomfort?"
4 • Closed-ended or direct questions require a simple answer, such as "yes" or "no."
5 – "Do you have pain now?"
6 – "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.
2 – It includes posture, actions, or words.
3 – The most helpful method of facilitation often is often making eye contact.
4 – Use phrases such as "Go on," "Please continue," or "I am listening" to encourage the
patient.
5 – Avoid saying "I am listening" when you are obviously doing something else (e.g., looking
at equipment).

.
• Reflection
1 – This involves repeating the patient's words (or your summary of them) back to make
certain you both are communicating.
2 – It encourages additional responses by the patient.
3 – Done properly, 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.
0 – At this stage, a few short, directed questions may be appropriate.
1 • "Now, you said that breathing makes your pain worse; is this mostly when you
breathe in, when you breathe out, or all the time?"
2 – Alternatively, you could ask an open-ended question:
"Now, you said that breathing made your pain worse; when during your breathing is the
pain made worse?

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Techniques of History Taking—Questioning Patients
1 • Empathetic responses
2 – Empathy is very different from sympathy.
3 – Though sympathy may be appropriate at some times, your job in history taking is
to be professional, kind, and empathetic.
4 – Try to identify with what the patient is going through.
5 – Express to the patient things such as:
← "You sound uncomfortable."
← "I'd probably be frightened if I were in your shoes."
6 • Confrontation
7 – It is more direct but potentially disruptive to your relationship with the patient.
8 – It may be extremely helpful under selected circumstances.
9 – Examples:
← "I'm here to help you—if I don't know what drugs you took, I can't do you much good."
← "I'm not any happier than you are that you hurt your leg; let yourself try to relax some
so I can help you out better."
10 – Rarely, simply saying something such as "Just do it!" is necessary for the best
outcome.

Techniques of History Taking—Questioning Patients

• Interpretation
1 – Interpretation requires you to synthesize what the patient has told you.
← 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.

–Example:
← The patient complains of neck, upper abdomen, and left arm pain.
← Based on answers to other questions, you suspect a possible heart attack.

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,especially those
that directly affect the current problem.
10 – Preexisting medical problems (e.g., diabetes) or surgeries
11 – Medications

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 12 – Allergies
13 – Medical care (e.g., family physician)
14 – Family history
15 – 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

← Ask the patient about tobacco use.
← Determine the use of alcohol, drugs, and other related substances.
← Note any special diet factors of interest.
1 • The "SAMPLE" acronym stands for:
2 – S—Signs and symptoms
3 – A—Allergies
4 – M—Medications
5 – P—Pertinent past medical history
6 – L—Last oral intake, fluid or solid
7 – 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.
1 • Consider the following to provide the best patient care possible:
2 – Always remain calm and professional.
3 – Appear completely nonjudgmental.
4 – Continually remind the patient that you are there to help.
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5 – Don't be too reassuring, because over-assurance may hamper communication.
6 – Remember that the competent patient has the right to refuse to divulge information to
you.
Special Challenges—Silent Patient
← A silence is sometimes rather frustrating and confusing.
← A silent patient often makes us feel uncomfortable.
← Silence does not necessarily show that the patient is hostile,problematic, or uncooperative.
← Patients may use silence as a way to collect their thoughts, remember details, or decide
whether they trust you.

Special Challenges—Silent Patient (cont.)

← The best approach, after being certain that the patient can hear and understand you, is
patience.
1 • Be alert for nonverbal clues of distress.–Grimacing
2 – Touching or rubbing a particular area repeatedly
3 – Sweating–Crying
← Under emergency circumstances, being talkative usually reflects that the patient is nervous
and scared.
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, breathing, or circulation (the ABC's)
must be identified rapidly and cared for.
3 – Once you have ruled out immediate life-threats, enlist patients to help you rank
their complaints.
Special Challenges—Anxious Patient

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← Everyone is usually anxious, to at least some extent, when sick or injured.
← Sometimes, people talk fast as a response.
← Others talk much slower or even become silent.
0 • Remember that much human communication is performed by nonverbal means.
1 – Pay close attention to these nonverbal clues.
← Use caution with reassurance.
← Anger and hostility are normal reactions to undesirable circumstances, such as illness
or injury.
← Although you are there to help, the patient may displace anger toward you.
← Much of the time, this is not done purposefully or with any bad intent.
← You must remain calm in your response to the patient.
← If there are perceived physical dangers, get appropriate assistance immediately.
← Do not place yourself in or allow yourself to remain in a potentially volatile situation.

Special Challenges—Crying Patient

← Crying may be the result of many factors, including pain and fear.
← Crying is expected in many children but occurs in adults as well.
← Use a gentle, calm, and professional approach.
← Remain objective and empathetic.
← The best way to deal with a crying patient may be to simply offer tissue paper.
← Depression ranges in severity from a temporary response to a situation to a severe
psychiatric illness that may result in violent behavior.
← Acceptance of the situation with empathy is the best communication technique.
← Avoid telling the patient things like "everything's all right," or "things will work out."
← Realize that the patient feels bad, and acknowledge it.

Special Challenges—Depressed Patient

• Signs of depression include:
1 – Sad appearance–Crying
2 – Inappropriate responses, especially crying, 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.
← A thorough history from bystanders and the patient can assist in narrowing in on the
cause.
← Remain sympathetic and professional with the patient, especially while attempting
to identify the cause of the patient's behavior.
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Special Challenges—Patient with Limited Intelligence
← Even patients with limited intellectual capacity can express their basic needs, feelings,
and symptoms if given a chance.
← Speak clearly, but normally.
← Expect to take more time than usual for the patient to respond to your question.
← Get additional information from family or friends.
← If patients are capable of communicating, direct your interview toward them first.
← Remember to be patient and professional.

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

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