NS-HAT 201 Topic 2: History Collection PDF

NS-HAT 201 Topic 2: History Collection Ms. Thushara Sekhar www.gmu.ac.ae Learning Objectives: On completion of this unit, the student will be able to: Identify the concept and principles of history taking Describe the Components of health history Demonstrate general app...

NS-HAT 201 Topic 2: History Collection Ms. Thushara Sekhar www.gmu.ac.ae Learning Objectives: On completion of this unit, the student will be able to: Identify the concept and principles of history taking Describe the Components of health history Demonstrate general approaches and techniques in history taking Explain the role of nurse in history taking. What is History Collection/ Health History? Asking questions to patients to obtain information and aid diagnosis. The systematic gathering of a information from patient or significant others. The health history includes the patient's primary concern, a history of the current illness, general medical and surgical histories, a family history, a social history etc… 5 Initiating the Session Preparation Prepare: 1. Yourself 2. The environment “If in a bad mood or distracted during the consultation, you can end up making a history rather than taking a history”. Initiating the Session Establish rapport - begin with a smile and an ice-breaker Initial greeting - Confirm the patient’s name and date of birth. Greet the patient with their title and surname Introductions – your full name and role Seek consent Respect the patient Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you proceed, ask the patients permission to do so. Active Listening Several nonverbal skills have been identified as facilitative skills for attentive listening. SOLER: S – Sit facing the client O – Observe an open posture L – Lean toward the client E – Establish and maintain eye contact R – Relax 8 Questioning Techniques 9 Open Questions Always start with an open question and listen to the patient’s story Open questions begin with: "What" "Why" "When" "How" "Which" Main features of open questions - They encourage conversation. They are good for finding out details They give ’control’ to the responder during conversation. They often start with ’what’, ’when’ ’why’, ’tell me’. 'describe’, etc. But, they take longer time, and one needs to be an active listener. 10 Closed Questions Closed questions have single short answers like, “yes”, "no", "don’t know." They force a person to give a brief answer. They usually provide a factual answer. Used to gain clarification. But, a misplaced question can stop conversation and lead to silence. Examples of closed questions: o “What is your name”? o ”Do you smoke”? o “What do you prefer, tea or coffee”? 11 Leading Questions Questions based on your own assumptions that leads the patient to the answer you want to hear. This should not be used at all. This type of questions are used when the questioner wants to get something confirmed. These are commonly used in legal cases Leading question can help you get the answer you want. Disadvantage: Biased leading question can render your data unusable and open to question. 12 Examples 1: Leading question: Do you have any problems with your wife? This question prompts the person to question their marital relationship. In a subtle way it raises the prospect that there are problems. Non-leading question: Tell me about your relationship with your wife. Examples 2: Leading question: “Were you at your house on 31st. night?” Non-leading question: “Where were you on 31st. December night?” 13 Development of Empathy Nurse must be receptive to the patients feeling and perceptions Nurse must understand the patients communication Nurse should be able to put himself/herself in the patient’s place and understand patients needs which they may not be able to communicate freely sometimes. For eg: After a painful experience the patient may not feel to have food. The nurse understands this and doesn’t force the patient. Empathy should not be confused with sympathy 14 Clarification Several therapeutic communication techniques, such as reflection, restatement, and clarification, help the nurse to send empathetic messages to the client. For example, a client says, “I’m so confused! My son just visited and wants to know where the safety locker key is.” Using reflection, the nurse responds, “You’re confused because your son asked for the safety locker key?” The nurse using clarification responds, “Are you confused about the purpose of your son’s visit?” 15  What is “data verification,” and how is it done? Data verification is the process through which data are validated as being complete and accurate. Data verification consists of : (1) reviewing the data for inconsistencies or omissions (2) observing nonverbal behavior to confirm or contradict a client’s perceptions (3) comparing data with norms, (4) rechecking and confirming grossly abnormal findings. 16 Common Pitfalls of History Taking Components of health history Patient Biographical Chief Complaints: information: History of Present illness: Name: Past Medical history: Name & Relation of Informant: Immunizations: Allergies: Gender: Age: Disease conditions: Date of Birth: Medications: Place of Birth: Past Surgical history: Present Address: Religion: Family history: Family medical history: Marital Status: Occupation: Genetic/Congenital diseases: Monthly family income: Admitting Consanguineous marriages: diagnosis: Family Tree:  HISTORY OF PRESENT ILLNESS This is the first admission for this 56 year old woman, who states she was in her Convey the acute or chronic nature usual state of good health until one week prior to admission. of the problem establish a chronology. At that time she noticed the abrupt onset (over a few seconds to a minute) of chest Onset pain which she describes as dull and aching in character. Character The pain began in the left para-sternal area and radiated up to location her neck. Location The first episode of pain one week ago occurred when she was working in her garden circumstances; exacerbating factors in the middle of the circumstances; exacerbating factors day. She states she had been working for approximately 45 minutes and began to feel tired before the onset of the pain. Associated symptoms Her discomfort was accompanied by shortness of breath, but no sweating, nausea, or Duration vomiting. The pain lasted approximately 5 to 10 minutes and resolved when she went Alleviating factors and resolution duration inside and rested in a cool area. Describe the natural history of her Since that initial pain one week ago she has had 2 additional episodes of pain, similar problem since its onset in quality and location to the first episode. Change or new circumstances to the This evening she had an episode of pain awaken her from sleep, lasting 30 minutes, problem which prompted her visit to the Emergency Department New duration Reason she come in for visit Sample family tree Types of Family Trees Consanguineous marriage Components of health history Menstrual and Obstetrical Personal history: history [if applicable]: Hygienic habits Length of cycle: Smoking/ Substance abuse Duration of cycle: Dietary pattern: Pain and other associated Dietary preferences: symptoms: Frequency and amount of food Number of children: intake: Type of childbirth/s: Food Allergies: Abortion/Still birth: Functional history: Any ante/intra/post natal Rest and sleep patterns complications: Bowel and bladder habits Socio-Economic history  Some examples of Subjective & Objective data Tachycardia- O Dizziness- S Unconsciousness- O Fatigue- S Nausea- S Hyperthermia- O Shortness of breath- S (can also be O if severe) Wheezing- O Vomiting- O Cough- O Itching- S Pain- S Tenderness- O 3 References Jarvis C, Eckhardt AL. Physical examination and health assessment. 9th ed. Philadelphia, PA: Elsevier - Health Sciences Division; 2023. ISBN-13: 978-0-323-80984-9. Unit 1, Chapter 4, Page no – 41- 57 Weber JR, Kelley JH. Health Assessment in Nursing. 7th Edition. Wolters Kluwer; 2021. ISBN: 13: 978-1-9751-6115-6.Unit 1, Chapter 2, Page Nos – 9 - 27 Hinkle JL, Cheever KH, Overbaugh KJ. Brunner & Suddarth’s textbook of Medical-Surgical Nursing. 15th Edition Philadelphia: Wolters Kluwer; 2022. ISBN-13: 978-1-9751-6103-3. Unit 1, Chapter 4, Page No – 71-94