HISTORY TAKING IN ENGLISH

                                           

                                HISTORY TAKING IN ENGLISH

                          watch my youtube video to understand this topic in easy way-

     https://www.youtube.com/watch?v=qdB4mqGg-9c

HEALTH ASSESSMENT (HISTORY TAKING)

}  A health assessment is a process to identify specific health needs and level of health status of a person . Basically health assessment involves two steps-

}  History taking and

}  Physical examination

HISTORY TAKING-

}  History taking is a part of health assessment which involves asking specific questions to the patient or the person who knows the patient and can give suitable information.  History taking is also known as interviewing of patient.

OBJECTIVES OF HISTORY TAKING-

•    To establish rapport with the patient

• To establish or maintain nurse-patient relationship for proper nursing care

•   To obtain information useful for diagnosis

•   To identify or clarify health problems

  • To give information to the client or to teach him or Her about health

• To counsel and/or assist the client in finding solutions to problems

PRINCIPLES OF HISOTRY TAKING-

}  Sit facing the client. Sitting suggests relaxation and indicates that time will be allowed for the interview.

}  Provide privacy, and attend to client’s comfort; for example, supply pillows for support, a footstool, or a glass of water.

}  Use simple language at first; increase complexity if client is able to understand.  

}  Explain the purpose of the interview, how long it will last, and how the information will be used.

}  Use narrow questions to help the client focus, such as “Do you have nausea with the vomiting?”

}  Use open-ended questions such as “How do the headaches begin?” to explore feelings and perceptions and to identify areas requiring follow-up.

}  look and listen carefully for clues, both verbal and nonverbal. Establish eye contact, avoid answering for the client, and explore clues in a nonthreatening manner.

}  Avoid interruptions and the appearance of being distracted or bored, such as looking at the clock or flipping pages in the record. Wait for answers. Silence encourages thinking and often produces verbal responses.

PROCESS OF HISTORY TAKING-

}  Start history taking by collecting personal data such as

}  Date of interview

}  Name

}  Gender

}  Date of birth

}  Place of birth

}  Age

}  Address

}  Person to be contacted in an emergency (name, relationship, address, phone number)

}  Education

}  Occupation (presently or before retirement)

PRESENT HEALTH HISTORY-

}  In this section e collect information about-

}  Present problems

}  Onset of problem

}  Location of symptoms

}  Chronology

}  Precipitating factors

}  Alleviating factors

}  Aggravating factors

}  Associated symptoms

}  Treatments

}  Client’s view of cause

PAST HEALTH HISTORY-

}  In this section e collect information about-

}  Client’s perception of level of health in general

}  Childhood illnesses (dates and types)

}  Genogram (family history of diseases)

}  Immunizations

}  Allergies

}  Serious accidents and/or injuries (dates)

}  Major adult illnesses (types and dates)

}  Behavioral problems

}  Surgical procedures (types and dates)

}  Other hospitalizations (types and dates)

}  Environmental hazards

PERSONAL HISTORY ( HABITS AND LIFE STYLE)-

}  Work: Type, length of time employed, stresses

}  Rest and/or sleep: How much, when, aids

}  Exercise and/or ambulation: How much, when

}  Recreation, leisure, hobbies: Type, amount

}  Nutrition: Time, foods, fluids, and amounts for all meals and snacks; recent changes in appetite; special diet

}  Alcohol and/or other drugs: Type, number of years used, amount, perceived problems with level of use

}  Tobacco: Type, number of years used, amount per day

}  Urinary and bowel activity: Frequency, amount, problems related to urinary and bowel activity

ADL (Activities of daily living)  -

}  Ambulating

}  Dressing

}  Grooming

}  Bathing

}  Toileting

}  Eating

}  Using the telephone

}  Doing laundry

}  Housekeeping

}  Preparing food

}  Driving

}  Purchasing food

PSYCHO-SOCIAL HISTORY-

}  The psychosocial history is important in any assessment that considers a holistic view of the client, especially in a community or long-term care setting. The psychosocial history involves the client’s relationship to others such as family members, friends, neighbors, colleagues at workplace and friends in social and civic organizations in the community

}  The psychosocial history includes-

}  Significant stressors

}  Coping ability

}  Feelings about self: Self-concept, functional status, adaptations, independence, body image, marital status etc.

}  History of interpersonal trauma: Rape, incest, abuse as child or spouse, other personal tragedies. Note ability to discuss, current stage in resolution  

}  • Periods of grief and current status

}  • Understanding of and feelings about current illness(es)

SYSTEMIC REVIEW OF SYMPTOMS-

}  The review of systems (sometimes called the review of symptoms) helps the nurse to focus on each major system of the body, noting from the health history which systems may have special problems. This systematic process prevents the omission of important assessment information.

}  It includes inquiry about

}  General symptoms

}  Integument (skin, hair, nails)

}  Head

}  Eyes

}  Ears

}  Nose and sinuses

}  Mouth and throat

}  Neck

}  Lungs and thorax

}  Breasts and axillae

}  Cardiovascular system

}  Abdomen

}  • Musculoskeletal system

}  • Male genitourinary system and rectum

}  • Female genitourinary system and rectum

}  • Neurologic

}  • Adaptations in pregnancy

FAMILY HISTORY-

}  This section includes history about-

}  Interview all family members at the same time to observe communication and decision-making patterns.

}  Assess each family member’s health.

}  Assess family’s health history

}    family health history also includes family member’s ages at death and causes of death.

}  Note patterns of illness distribution across generations(for example, cancer and heart disease).

}  • Assess family structure: Single, nuclear, joint

COMPLETION-

}  Ask whether there is anything else that the client would like to tell or ask you. Assure the client that information provided by him ill be kept confidential and ill be used only for health care plan of him/her.