HISTORY

TAKING
 Aim

• Obtain data to
– Make a nursing diagnosis,
– Identify and implement nursing interventions
– Assess effectiveness of nursing interventions.

• To establish a relationship with the patient.

 Art of history taking
• Beginning of nurse – patient relationship.

• Put the patient at ease and encourage him to

talk freely.

• Be friendly, say who you are and your role.

• Establish eye contact.

• Open the consultation with some general
question such as “ what can I do for you? Or
“How can I help you? Or “what’s the trouble?

• If you are a student do not hide it.

• Pronounce patient’s name correctly.

• Address the patient properly ( Mr, Mrs, Miss).

• Never use a surrogate term for the patient’s

name, e.g. mother, father.

• Be seated at an easy distance from the

patient, comfortably and without any
furniture barriers between you.
• Listen to the patient carefully.

• Avoid interruptions unless you really have to.

• The person has the right to know why the

information is sought and how it will be used
 Sensitive issues
• Not easy to question a patient on sensitive
issues like sex.

• Still they must not be avoided.

• There is no specific “right” way to deal with

these questions but you must feel
comfortable with your approach.
 Guides to questioning
• Privacy is essential

• Do not waffle, be direct and firm.

• Do not preach.

• Do not be judgmental.
• Use language that is understandable to client.

• Do not push too hard.

• If the patient is defensive, recognize that the

patient feels that defense is necessary.
OUTLINE OF CLINICAL HISTORY: BODY SYSTEMS
MODEL
Biographical data
• Personal details of patient

• Includes
– Name, Address, Age, Gender, Marital status,
Occupation,Ethnic origins.
 Chief Complaint
• What really made the patient seek care

• Questions to ask
– “What problems or symptoms brought you here?”
– “Why have you come to the health center today?”
– “Why were you admitted to the hospital?”

• Determine duration of the illness.

 History of Presenting Illness
• Details of the current problem(analysis of s/s)

• Recorded in chronological order from onset to

time of contact with health care provider e.g.
– Patient was well until ……
– The patient first experienced head ache 1 month
before seeking care
• State of health just before the onset of the
present problem.

• Possible exposure to infection or toxic agents.

• Immediate reason that prompted the seeking of

attention.

• Medication: current and recent, including dosage

of prescription and home remedies.
• Impact of the illness on the patient’s usual
life-style ( marriage, leisure activity).

• “Stability” of the problem, does its intensity

vary.
• Describing how problem started (Onset)
– Date and manner (sudden or gradual)
– setting in which the problem occurred (at home,
at work, after an argument, after exercise),
– manifestations of the problem,
– the course of the illness .
– Treatments taken, progress and effects of
treatment, and the patient’s perceptions of the
cause or meaning of the problem.
• Specific symptoms are described in detail
– location and radiation (if pain),
– quality,
– Severity
– duration.

• Is problem persistent or intermittent,

– what factors aggravate or alleviate it,
– associated manifestations.
 Past Medical History
• A detailed summary of client’s past health

• Helps in assessing the present complaint.

• Assists to identify risk factors that stem from

previous health problems

• Includes
– General health status.
– Childhood illnesses e.g. measles
– Major adult illnesses: tuberculosis, hepatitis,
diabetes, hypertension, heart diseases.

– Immunization status: polio, diphtheria, pertussis,

tetanua toxoid, influenza, cholera, typhus, bacilli
Calmette-Guerin(BCG) etc.

– Surgery and hospitalization: dates, hospital,

diagnosis, complications.
– Serious injuries resulting to disability.

– Limitation of ability to function as a result of past

events.

– Medications: past, current and recent medications

– Allergies

– Transfusions: reactions, date, number of units.

– Emotional status: mood disorders,

– psychiatric disorders.

– Previous investigations and results

• Sample questions
– Birth.
• “Can you tell me how your mother described your
birth?
• Were there any problems?
• As far as you know, did you progress normally as you
grew to adulthood?
• Were there any problems that your family told you
about or that you experienced?”
– Childhood diseases & immunization
• “What diseases did you have as a child such as measles or
mumps?
• What immunizations did you get and are you up to date
now?”

– Chronic illness
• “Do you have any chronic illnesses?
• If so, when was it diagnosed?
• How is it treated?
• How satisfied have you been with the treatment?”
– Previous illness/allergy
• “What illnesses or allergies have you had?
• How were the illnesses treated?”

– Hospitalizations/surgery
• “Have you ever been hospitalized or had surgery?
• If so, when?
• What were you hospitalized for or what type of surgery
did you have?
• Were there any complications?”
– Accidents/injuries
• “Have you experienced any accidents or injuries?
• Please describe them.”

– pain
• “Have you experienced pain in any part of your body?
• Please describe the pain.”
– Mental problems
• “Have you ever been diagnosed with/treated for
emotional or mental problems?
• If so, please describe their nature and any treatment
received.
• Describe your level of satisfaction with the treatment.”
 Family History

• Blood relatives in the family who have

illnesses with features similar to the patient’s
illness.

• Ethnicity, health, or cause of death of parents

and siblings, including their ages at death.
• Hereditary disease such as sickle cell disease
– History of grandparents, aunts, uncles, siblings
and cousins concerning hereditary diseases.

• History of familial disease like heart disease,

high blood pressure, cancer, tuberculosis,
stroke.
 Personal and Social History

• Personal status
– Birthplace, where raised, home environment,
socioeconomic class, cultural background,
education, position in family, marital status,
general life satisfaction, hobbies, interests,
sources of stress, strain.
• Habits
– Nutrition and diet, regularity and patterns of
eating and sleeping, exercise, alcohol, illicit
drugs(frequency, type and amount), quantity of
tea, coffee, tobacco, breast or testicular self
examination.
• Sexual history
– concerns with sexual feelings and performance
– frequency of intercourse
– ability to achieve orgasm
– numbers and variety of partners.
• Occupation
– description of usual work and present work if different
– list of job changes
– work conditions and hours
– duration of employment

• Religious preferences
– Any religious proscriptions concerning medical care.
 Others

• Developmental history
 Review of Systems

• All major systems are reviewed

• Ask specific questions to draw out current

health problems or problems from the recent
past that may still affect the client or that are
recurring.

• Include only the client’s subjective information

and not the examiner’s observations.
– General
• weight, sleep, energy

– GIT, abdomen and pelvis

• pain, appetite, vomiting, general characteristics of vomited
matter, flatulence, heartburn, dysphagia, diarrhoea,
constipation.
• Liver and gall bladder – jaundice, pain.

– Genital system
• ulcers, discharge, pain.
– Cardiovascular system
• Dyspnoea, pain or tightness, palpitation, cough, edema,
other symptoms.
• The blood :Dyspnoea and awareness, infections, blood
loss, skin problems, diet, past history, drug history

– Respiratory system
• Cough, sputum, breathing, wheeze, chest pain.
– Urinary system
• symptoms suggestive of renal failure, urine

– Nervous system
• stroke, epilepsy, common neurological symptoms.

– Locomotor system
• muscles : tonicity
• Infants and children : special questions where relevant.
 Children
Chief complaint
• History taken from a parent or other responsible
adult.

• Include child as appropriate for his/her age.

• Latent fears underlying any chief complaint of

both parents should be explored.

• Note the relationship of the person providing the

history for the child.
 Present Problem or Illness

• The degree and character of the reaction to

the problem on the part of parent and child
should be noted.
 Past Medical History

• General health and strength

– Depending on the age of the patient or nature of
the problem, different aspects of the history
assume or loose importance

– Reserve detailed questioning for those aspects

most pertinent to the age of the child.
• Mother’s health during pregnancy
– General health, prenatal care.

– Specific diseases or conditions

• Infectious disease (approximate gestational month),
weight gain, edema, hypertension, proteinuria,
bleeding.

– Medications, hormones, vitamins, special or

unusual diet, general nutritional status.
– Quality of fetal movements and time of onset.

– Emotional and behavioral status(attitudes toward

pregnancy and children).

– Radiation exposure.

– Use of illicit drugs.

• Birth
– Duration of pregnancy, place of delivery.
– Labor:
• spontaneous or induced, duration, analgesia or
anesthesia, complications.

– Delivery:
• presentation, forceps, vacuum extraction, spontaneous
or caesarian section; complications.
• Condition of infant, time of onset of cry, apgar score.
• Birth weight of infant.
• Neonatal period
– Congenital anomalies; baby’s condition in
hospital, oxygen requirements, colour, feeding
characteristics, vigor, cry;

– Duration of baby’s stay in hospital

– Bilirubin phototherapy, prescriptions

– First month of life
• Jaundice, color, vigor of crying, bleeding, convulsions,
or other evidence of illness.

– Degree of early bonding

• Opportunities at birth and during the first days of life
for the parents to hold, to talk, and caress the infant
• Feeding
– Bottle or breast, reason for changes if any; type of
formula used, amounts offered and consumed,
frequency of feeding and weight gain.

– Present diet and appetite; age of introduction of

solids; present feeding patterns, any feeding
problems; age weaned from bottle or breast; type
of milk and daily intake; food preference; ability to
feed self.
• Development
– Age when able to:
• hold head erect while in sitting position,
• roll over from front to back and back to front,
• sit alone and unsupported,
• stand with support alone,
• walk with support alone,
• use words, talk in sentences, dress self.
– Age when toilet trained:
• approaches to and attitudes regarding toilet training.

– School:
• grade, performance, problems.

– Dentition:
• age of first teeth, loss of deciduous teeth, eruption of
first permanent teeth.
 – Growth:
• height and weight in a sequence of ages; changes in
rates of growth or weight gain.

• Sexual:
– present status:
• in female, development of breasts, nipples, sexual
hair, menstruation (description of menses);
• in male, development of sexual hair, voice changes,
acne, nocturnal emissions.
• Illnesses:
– immunizations,
– communicable diseases,
– injuries,
– hospitalizations.
 Family History

• Obtain a maternal gestational history,

– List all pregnancies together with the health
status of living children.

• For diseased children include date, age, cause

of death and dates and duration of
pregnancies in the case of miscarriages.
• Mother’s health during pregnancies and the
ages of parents at the birth of this child.

• Are parents related?

• A review of at least two generations on each

side of the family is desirable.
 Personal and social History

• Personal status:
– School adjustment, masturbation, nail biting,
thumb sucking, breath holding, temper tantrums,
pica, rituals, bed wetting, constipation or fecal
soiling of pants, reactions to prior illnesses,
injuries or hospitalization.
• Home conditions:
– Father’s and mother’s occupation,
– The principal caretakers of the child,
– Parents divorced or separated,
– Educational attainment of parents,
– Cultural heritages;
– Food prepared by whom,
– Adequacy of clothing,
– Dependence on relief or social agency,
– Number of rooms in house and number of
persons in household;
– Sleep habits, sleeping arrangements available for
the child.
• Review of Systems.
 Pregnant women
Chief Complaint
• The following information is included:
– patient’s age, marital status, gravidity and parity,
last menstrual period, previous usual menstrual
period, expected date of confinement/delivery,
occupation, and father of the baby and his
occupation.
 Present Problem

• A description of the current pregnancy and

previous medical care.

• Attention is given to specific problems, e.g.

– nausea, vomiting, fatigue, edema.
 Obstetric History

• Information on each pregnancy includes

• date of delivery, length of pregnancy, weight and
sex of infant, type of delivery (spontaneous
vaginal, cesarean section and type of scar), length
of labor, complications in pregnancy or labor,
postpartum, or with the infant.
 Medical History

• The same information as identified previously

is obtained, with the addition of risk factors
for AIDS, hepatitis, tuberculosis, and exposure
to environmental and occupational hazards.

• A mother who had intrauterine growth

restriction (IUGR) carries this risk factor for
her children.
 Family History

• In addition to the information obtained

previously, a family history of genetic
conditions, twins, and/or congenital
anomalies is obtained.
 Personal and Social History

• Additional information includes

– Feelings toward the pregnancy,
– Whether the pregnancy was planned,
– Preference for sex of child,
– Social supports available,
– Experiences with motherhood and history of
abuse in relationships.
 Review of Systems

• Effects of pregnancy are seen in all systems,

but special attention is given to the
reproductive and cardiovascular systems.
 Risk assessment

• Encompasses identifying from the history and

physical examination those conditions that
threaten the well-being of the mother and/or
fetus.

• Examples of risks: diabetes, preterm labor,

preeclampsia, eclampsia, pregnancy-induced
hypertension.
FUNCTIONAL HEALTH PATTTERNS APPROACH
TO HISTORY TAKING
• Handout
Thank you