R.

Gundo
Medical/Surgical Nursing
Department

History Taking
History Taking
 At the end of the unit, students should be able take
history of a client/patient.

History Taking
 The essential elements for health history include:

◦ Empathic listening

◦ The ability to interview patients of all ages, moods, and

backgrounds

History Taking
◦ The process of clinical reasoning i.e.
 identifying problem symptoms and abnormal
findings;

 Linking findings to an underlying process of

pathophysiology or psychopathology;

 Establishing and testing a set of explanatory

hypotheses.

History Taking
Subjective Data
 What the patient tells you
 The history, from chief
complaint through Review of
Systems
 Example: Mrs. G is a 54-year-old
housewife who reports pressure
over her left chest “like an elephant
sitting there,” which goes into her
left neck and arm.
Objective Data
 What you detect on the
examination
 All physical examination
findings
 Example: Mrs. G is a middle aged
lady, well nourished, pleasant, and
cooperative.
 BP 160/80, HR 96 and regular,
 Respiratory rate 24, afebrile.
History Taking
 The health history interview is a nurse patient/client
conversation with a purpose.
 The primary goal of the nurse–patient interview is to
improve the well-being of the patient.
 Basically, the purpose of the conversation with a
patient is threefold:

◦ To establish a trusting and supportive relationship,

◦ To gather information
◦ To offer information.

History Taking
 The kinds of questions you ask as you elicit the
health history vary according to several factors. The
scope and degree of detail depends on:

◦ the patient’s needs and concerns

◦ the nurses goals for the encounter

◦ the clinical setting (e.g., inpatient or outpatient, primary care or

subspecialty).

◦ The amount of time available

History Taking
◦ For new patients, regardless of the setting, a comprehensive
health history, is done

◦ For other patients who seek care for a specific complaint, such
as a cough or abdominal pains, a more limited interview
tailored to that specific problem sometimes known as a
problem-oriented history, may be indicated .

History Taking
For adults, the comprehensive history includes:
 Identifying Data and Source of the History,
 Chief Complaint(s),
 Present Illness,
 Past History,- Med, surge.
 Family History,
 Personal and Social History, and
 Review of Systems.

History Taking
 The date is always important.

 It is important to routinely document the time you

evaluate the patient especially in urgent, emergent, or
hospital settings.

History Taking
 Identifying Data - Such as name, age, gender,
occupation, marital status, physical address,
nationality, religion, next of kin
 Source of the History - Usually the patient, but
can be family member, friend, letter of referral, or
the medical record.
 Source of Referral - If appropriate, establish
source of referral, since a written report may be
needed.

History Taking
 Should be documented if relevant.

 For example, “The patient is vague when describing

symptoms and unable to specify details.”

 This judgment reflects the quality of the information

provided by the patient and is usually made at the end
of the interview.

History Taking
 The one or more symptoms or concerns causing the
patient to seek care

 Reason for admission

 Make every attempt to quote the patient’s own words.

 For example, “My stomach hurts and I feel awful.”

History Taking
 Sometimes patients have no overt complaints, in
which case you should report their goals instead.

 For example, “I have come for my regular check

up”;

 or “I’ve been admitted for a thorough evaluation

of my heart

History Taking
 This section of the history is a complete, clear,
and chronologic account of the problems
prompting the patient to seek care.

 It amplifies the chief complaint, and describes

how each symptom developed

 The narrative should include:

◦ The onset of the problem,
◦ the setting in which it has developed

History Taking
 ◦ Its manifestations,
◦ and any treatments.

 The principal symptoms should be well-

characterized, with descriptions of:

1. Location,
2. Quality,
3. Quantity or severity,
4. Timing, including onset, duration, and frequency,

History Taking
5. The setting in which they occur.
6. Factors that have aggravated or relieved the
symptoms, and
7. Associated manifestations.

History Taking
 Lists childhood illnesses such as measles,
chicken pox, polio.
 Also included are any chronic childhood
illnesses
 Also lists adult illnesses with dates for at least
four categories:
1. Past Medical History- (such as diabetes,
hypertension, hepatitis, asthma, HIV and AIDS,
information about hospitalisations, number and
gender of partners;
2. Past Surgical History - (includes dates,
indications, and types of operations);

History Taking
 Obstetric/Gynaecologic - (relates obstetric history,
menstrual history, contraceptive use, and sexual
function); and gyn hx;repro track dizz,stds,..
 Psychiatric (includes dates, diagnoses,
hospitalisations, and treatments).
 Past history also includes health maintenance practices
such as:
◦ immunizations,
◦ screening tests such as pap smears
 Together with the results and the dates they were last
performed.

History Taking
  An Outline of age and health, or age and cause of death
of siblings, parents, and grandparents.
 Documents presence or absence of specific illnesses in
family, such as:
◦ Hypertension,
◦ Diabetes,
◦ Thyroid or renal disease,
◦ Cancer,
◦ Arthritis,
◦ Tuberculosis, asthma or lung disease,
◦ Headache, seizure disorder, mental illness, and
◦ Allergies,
◦ As well as symptoms reported by the patient, etc.

February 2011
History Taking
 It captures the patient’s personality and interests,
 Sources of support, coping style, strengths, and fears.
 It Includes:
◦ occupation and the last year of schooling;
◦ home situation and significant others;
◦ sources of stress, both recent and long-term; important life
experiences such as, job history, financial situation, and
retirement;
◦ leisure activities; alcohol/smoking?
◦ religious affiliation and spiritual beliefs; and activities of daily
living (ADLs).

History Taking
 The Personal and Social History also conveys
lifestyle habits that promote health or create risk
such as:

◦ exercise and diet, including frequency of exercise, usual

daily food intake, dietary supplements or restrictions, and
drugs and alcohol

 You may want to include any alternative health care

practices such as use of herbs or medication.

History Taking
 Documents presence or absence of common
symptoms related to major body systems
 A series of questions are asked from head

to toe
 The review may uncover problems that the

patient may have overlooked, particularly in

areas unrelated to the present illness
 General
 Skin
 Head, Eyes, Ears, Nose, Throat
 Breasts
 Respiratory
 Cardiovascular
 Gastrointestinal
 Urinary
 Genital
 Peripheral vascular
 Musculoskeletal
 Neurological
 Haematological
 Endocrine
 Psychiatric
 Before Interviewing patients to obtain a health history:
 Take Time for Self-Reflection - look inward to clarify how
your own expectations and reactions may affect what you hear
and how you behave.

 Review the Chart - before seeing the patient, review his or her
medical record, or chart to gather information, and to develop
ideas about what to explore with the patient.
 Review your Behavior and Appearance.

History Taking
 Create rapport - As you begin, greet the patient by name and
introduce yourself, giving your own name. If possible, shake
hands with the patient. If this is the first contact.

 Explain your role, including your status as a student and how

you will be involved in the patient’s care.

 When visitors are in the room, it is important for you to maintain

confidentiality/let the patient decide if visitors or family
members should remain in the room, and ask for the patient’s
permission before conducting the interview in front of them.

History Taking
 It is important to ensure the patient’s comfort.
 After greeting the patient, ask how the patient is
feeling and if you are coming at a convenient
time.
 Look for signs of discomfort, such as frequent
changes of position or facial expressions that
show pain or anxiety.
 Arrange the bed to make the patient more
comfortable

History Taking
 The sitting arrangement should promote
effective communication, without invading
the patients personal space, or being
intimidating

 Give the patient your undivided attention. Try not to

look down to take notes or read the chart, and spend
enough time on small talk to put the patient at ease.

History Taking
 Once you understand the patient’s concerns and have elicited
a careful history, you are ready to begin the physical
examination.

 The comprehensive physical examination is conducted on

most new patients or patients being admitted to the hospital.

 For more problem-oriented, or focused, assessments, the

presenting complaints will dictate what segments of the
examination should be performed.

History Taking
 The key to a thorough and accurate physical examination is
developing a systematic sequence of examination.

 It is important to minimize the number of times you ask the

patient to change position from supine to sitting, or standing to
lying supine.

 Some segments of the physical examination are best obtained

while the patient is sitting, such as examinations of the head and
neck and of the thorax and lungs, whereas others are best
obtained supine, such as the cardiovascular and abdominal
examinations.

History Taking
 Most patients view the physical examination with at
least some anxiety.

 They feel vulnerable, physically exposed,

apprehensive about possible pain, and uneasy about
what you may find.

 At the same time, they appreciate your concern about

their problems and respond to your attentiveness.

History Taking
 With these considerations in mind, you should be:
◦ thorough without wasting time,
◦ systematic without being rigid,
◦ gentle yet not afraid to cause discomfort should this be
required.

 You should:
◦ examine each region of the body, and at the same time sense
the whole patient.
◦ note the wince or worried glance, and
◦ share information that calms, explains, and reassures.

History Taking
 Adjust the lighting and the environment

 It is important to “set the stage” so that both you and the

patient are comfortable. As the examiner, you will find that
awkward positions impair the quality of your observations.

 Take the time to adjust the bed to a convenient height (but be

sure to lower it when finished!), and ask the patient to move
toward you if this makes it easier to examine a region of the
body more carefully

History Taking
 Good lighting and a quiet environment are very
important when examining patients.

 Promote the Patient’s Comfort. Show concern for

privacy and patient modesty. This helps the patient
feel respected and at ease.

 Be sure to close nearby doors and draw the curtains

in the hospital or examining room before the
examination begins.

History Taking
 Drape the patient with the gown or draw sheet as you
examine the patient so that you visualize one area of the
body at a time. This preserves the patient’s modesty but
also helps you to focus on the area being examined.

 To help the patient prepare for segments that might be

awkward, briefly describe your plans before starting the
examination.

History Taking
 Keep the patient informed, especially when you
anticipate embarrassment or discomfort.
 Make sure your instructions to the patient at each step
in the examination are courteous and clear. For
example, “I would like to examine your heart now, so
please lie down.”
 As in the interview, be sensitive to the patient’s
feelings and physical comfort, watching the patient’s
facial expressions and even asking “Is it okay?”

History Taking
History Taking