HISTORY TAKING

BY
MAGNUS CHINEDU APUANU
PhD(c), DPA(c), MSc.(Midwifery), MSc.(OH&S), MSc.(Medical Education), MPA(Executive), MPH, PGDE,
PGCert(Nuclear Science), AdvDip(Critical Care Nursing), BNSc, RN, RM, RPHN, RCCN, RNE, AEP,
CMC, MNIM, MISPN, FIMC, FCP.

NSC 301.1: MEDICAL-SURGICAL NURSING I

DEPARTMENT OF NURSING
UNIVERSITY OF PORT HARCOURT
 History Taking
1
Introduction/Definition
2
Components of Nursing Health History
REVIEW OF PREVIOUS CLASS

 Patient/Client Assessment
 Introduction
 History taking in nursing refers to the systematic process
of gathering information about a patient's health history,
current health status, symptoms, concerns, and relevant
psychosocial factors.
 Health history is a comprehensive record of the patient's
past and current health.
 The health history of patients is obtained through
interview.
 During a health history, the nurse collects subjective data
from the patient, their caregivers, and/or family members
using focused and open-ended questions.
 Introduction
 The health history performed by the nurse (Nursing health
history) has a different focus from the medical history
performed by the physician.
 A medical history is designed to collect data to be used
primarily by the physician to diagnose a health problem
and it usually collected by the medical team.
 The medical history focuses on the disease rather than on
the patient and the patient's lifestyle practices.
 A nursing history on the other hand has a different focus –
the client’s response to the health problems, which assist
the nurse more accurately in identifying nursing diagnoses.
 Introduction
 While the medical history concentrates on symptoms and
progression of disease, the nursing history focuses on
client’s functional patterns, responses to changes in health
status and alterations in lifestyle.
 Although nursing and medical histories tend to overlap in
some areas, neither format alone presents a true picture
of the patient's total health status and health needs.
 Combining the nursing and medical history into one
format, the complete health history, provides the most
comprehensive source of information for assessing the
patient's total health needs.
Components of Nursing Health
History

Health History
Biographic Data

Important Health
Information
Functional Health
Patterns
 Biographic Data
 Biographic data provide a data set from which the nurse
can begin to make clinical judgments.
 The biographic data include the patient's name and
address, age and date of birth, birthplace, gender,
marital or relationship status, sexual orientation label,
race, religion, occupation, health insurance information,
and the reliability of the source of information.
 Name: Listening to the patient state his or her name
provides the first opportunity to assess the patient's
ability to hear and speak
 Biographic Data
 Address: The patient's address reveals information about the
patient's environment.
 The nurse will associate the environment with known health
benefits and risks.
 For example, individuals living in crowded urban
environments are at risk for problems associated with heavy
vehicular traffic, including respiratory problems from exhaust.
 Age and Date of Birth: Establishing the age of the patient
permits the nurse to begin evaluation of individual
characteristics in relation to norms and expectations of
physical and social characteristics across the age span.
 Biographic Data
 For example, the skin of a 20-year-old is expected to be smooth
and elastic, while the skin of a 70-year-old would be expected to
have wrinkles and decreased elasticity.
 Gender: There are health risks associated with sexual
differences.
 For example, although breast cancer can occur in males, it occurs
more frequently in females.
 Osteoporosis occurs in both sexes; however, postmenopausal
females are at greater risk.
 Adolescent males are at greater risk for injury from motor vehicle
accidents than are females; however, adolescent females have a
higher incidence of eating disorders than do adolescent males.
 Biographic Data
 Marital Status: Marital status indicates whether the
patient is single, married, widowed, or divorced.
 The patient's marital or relationship status provides
initial information about the presence of significant
others who may provide physical or emotional
support for the patient.
 Sexual orientation: Sexual orientation labels include
straight (heterosexual), gay, lesbian, and bisexual.
 Biographic Data
 Sexual practices and an individual's self-identified
sexual orientation label may provide insight about a
number of potential health risks.
 Compared to heterosexual men, gay, bisexual and
transgender men are 2 to 2.5 times more likely to
smoke, and compared to heterosexual women,
lesbian, bisexual and transgender women are 1.5 to
2.0 times more likely to smoke.
 Complications related to obesity, which is more
prevalent among bisexual and lesbian individuals.
 Biographic Data
 Issues related to use of anabolic steroids or club drugs,
as well as complications associated with human
immunodeficiency virus (HIV) infection, especially
among homosexual men.
 Race: Race refers to classification of people according
to shared biologic and genetic characteristics.
 African Americans have a higher incidence of
hypertension and peripheral arterial disease than
Caucasians.
 Caucasians and Asians are at highest risk for developing
osteoporosis.
 Biographic Data
 Religion: Religious beliefs often influence perceptions
about health and illness.
 Religions can impose certain restrictions that impact
health, such as not eating pork in the Jewish and
Muslim religions.
 Occupation: Information about the patient's
occupation is important in determining whether
physical, psychological, or environmental factors
associated with work impact the patient's health.
 For example, coal mining is associated with black lung
disease.
 Biographic Data
 Source of Information and Reliability: The biographic data
must identify the source of the information for the health
history.
 The usual source of information is the patient, who is the
primary source. Secondary sources of information include
family members, friends, healthcare professionals, and others
who can provide information about the patient's health status.
 Reliability of the source means that the person providing
information for the health history is able to provide a clear
and accurate account of present health, past health, family
history, psychosocial information, and information related to
each of the body systems.
 Biographic Data
 The patient is considered to be the most reliable source.
 Determining reliability of the patient includes assessing the
ability to hear and speak and the ability to accurately recall
health-related past events.
 However, parents or guardians must serve as the source of
information for children.
 Secondary sources are used when the patient cannot
participate in the interview because of physical or emotional
problems.
 Secondary sources are selected when their knowledge of the
patient is sufficient to provide thorough and accurate
information.
 Important health information
History of present
Important health information illness

Past health history

Important health information
Family history
provides an overview of past
and present health conditions
Psychosocial and treatments.
history
Review of body
systems
 History of present illness
 The history of present illness is a complete, clear, and
chronologic account of the problems prompting the
patient to seek care.
 It includes information about all of the patient's
current health-related issues, concerns, and problems.
 It reveals the patient’s responses to the symptoms
and the effect the illness has had on daily living.
 History of present illness covers the following:
 Onset: When did the symptoms or health issue first
begin? Was there a specific event or trigger?
 History of present illness
 Duration: How long have the symptoms been
present? Have they been constant or intermittent?
 Characteristics: What are the specific qualities or
characteristics of the symptoms? What is it like? For
example, is the pain sharp or dull?
 Location: Where on the body are the symptoms
localized? Does the pain radiate to other areas?
 Severity: How severe are the symptoms on a scale
from mild to severe? How do they impact daily
activities?
 History of present illness
 Aggravating/Alleviating Factors: What makes the symptoms
better or worse? Are there any factors or activities that
exacerbate or relieve the symptoms?
 Associated Symptoms: Are there any other symptoms occurring
in conjunction with the primary complaint? For example, are
there associated fever, chills, cough, or changes in bowel habits?
 Previous Treatment: Has the patient tried any self-care measures
or received treatment for the symptoms? If so, what was the
response?
 Impact on Function: How do the symptoms affect the patient's
daily functioning, work, or activities of daily living?
 Past History
 The past health history provides information about the
patient’s prior state of health.
 The past history includes information about childhood
diseases; immunizations; allergies; blood transfusions; major
illnesses; injuries; hospitalizations; labour and deliveries;
surgical procedures; mental, emotional, or psychiatric health
problems; and the use of alcohol, tobacco, and other
substances.
 The nurse asks the patient about major childhood and adult
illnesses, injuries, hospitalizations, and surgeries.
 Family History
 The family history is a review of the patient's family to
determine if any genetic or familial patterns of health or
illness might shed light on the patient's current health
status.
 For example, if the patient has a family history of type 1
diabetes, the nurse will question the patient closely about
signs of the disease. These signs include increased appetite,
frequent urination, and weight loss.
 The family history begins with a review of the immediate
family, parents, siblings, children, grandparents, aunts,
uncles, and cousins.
 Family History
 Family history is useful in establishing a basis to
predict risk (or susceptibility) for common diseases
such as diabetes, cancer, and heart disease.
 Knowing an individual's disease risk can be used to
personalize health care, targeting interventions to
those who will benefit most.
 If a person is found to have a strong family history of
diabetes, for example, a personalized strategy for
diabetes prevention and screening can be
recommended.
 Family History
 A patient with a strong family history of colorectal
cancer may be advised to have a first colonoscopy at
age 30, rather than the standard recommendation of
age 50.
 Family history information is elicited and depicted in a
pedigree (genogram, genetic chart or family tree).
 A pedigree is a graphic representation or diagram that
depicts both medical history and genetic relationships.
 In a pedigree, each family member is represented by a
symbol, using a circle for females and a square for males
 Family History
 In a pedigree, each family member's health information is
coded and printed below their symbol.
 The result is a visual representation of a family's health
information in the context of genetic relationships, allowing
easy identification of disease incidence and patterns of
inheritance.
 A family history should include at least three generations; if
the proband (the person around whom the pedigree is
created) has children, often four generations are depicted.
 It is useful to begin with the proband and then “build” the pedigree
by adding the most closely-related family members.
 Family History
 Include first, second, and third-degree relatives (i.e.,
parents, siblings and children, aunts, uncles, and
grandparents, and first cousins).
 Depict members of each generation along the same
horizontal plane.
 Record coded health information under each individual's
symbol.
 At the top of the pedigree, indicate the ancestry (origin) of
individuals in the originating generation
 Psychosocial History
 The psychosocial history includes information about
the patient's occupational history, educational level,
financial background, roles and relationships,
ethnicity and culture, family, spirituality, and self-
concept.
 The information about occupation, education, and
finances provides the nurse with cues about previous
experiences that may impact current or future health.
 A patient's occupational history can reveal risk factors
for a variety of problems.
 Psychosocial History
 For example, coal mining increases the risk for respiratory
diseases, truck driving is associated with kidney disease,
and exposure to asbestos in the shipbuilding and
construction industries is associated with lung cancer.
 Determining the patient's level of education establishes
expectations related to the ability to comprehend verbal
and written language.
 The patient's financial situation, that is, the ability to obtain
health insurance or pay for health services, has an impact
on health, health practices, and health-seeking behaviours.
 Psychosocial History
 Low income is associated with a lowered health status
and predisposition to illness.
 The nurse will also gather information about the
patient's roles and relationships, family, ethnicity and
culture, spirituality, and self-concept.
 The information provides an initial impression of the
family dynamics and informs the nurse of religious
and spiritual needs of the patient
 Review of Systems
 This is the systematic collection of specific information
about the client’s past and present health status
related to common problems of body systems.
 The focus of this portion of the health history is to
uncover current and past information about each
body system and its organs.
 The nurse asks the patient about system function and
any abnormal signs or symptoms, paying special
attention to gathering information about the
functional patterns of each system.
 Review of Systems
 The Review of Systems questions may uncover
problems that the patient has overlooked, particularly
in areas unrelated to the present illness.
 The systems included in this part of history taking are:
 Skin, Hair, and Nails
 Head, Eyes, Ears, Nose, Throat (HEENT); Neck; Breasts and
Axillae; Respiratory system; Cardiovascular System;
Gastrointestinal system; Peripheral vascular system;
Urinary System; Reproductive System; Musculoskeletal
system; Neurological; Psychiatric; Endocrine; and
Hematologic system.
Skin, Hair, and Nails
 The skin, hair, and nails are the
major components of the
integumentary system.
 A thorough assessment of the skin,
hair, and nails provides valuable
clues to a patient's general health.
 The skin, hair, and nails can suggest
the status of a patient's nutrition,
airway clearance, thermoregulation,
and tissue perfusion.
Skin, Hair, and Nails
 The skin review covers any changes
in the skin, such as rashes, itching,
dryness, lesions, discolouration, or
changes in moles.
 It helps to identify dermatological
conditions or systemic illnesses that
may manifest on the skin.
Head, Eyes, Ears, Nose, Throat
(HEENT)
 This review involves questions
about headaches, vision changes,
eye pain, redness, discharge,
hearing loss, ear pain, nasal
congestion, sinus pressure, sore
throat, difficulty swallowing, or
changes in taste or smell.
Neck
 Swollen gland
 Goiter
 Lumps
 Neck Pain
 Stiffness in the neck
Breasts and Axillae

 Lumps, pain, or discomfort

 Nipple discharge
 Self-examination practices
 Last mammogram
Respiratory System
 The respiratory review covers
symptoms such as cough, sputum
production, wheezing, shortness of
breath, chest tightness, or hemoptysis
(coughing up blood).
 It helps to assess for respiratory
infections, asthma, chronic obstructive
pulmonary disease (COPD), or other
pulmonary conditions.
Cardiovascular System
 The cardiovascular review includes
questions about chest pain, palpitations,
shortness of breath, orthopnea
(difficulty breathing when lying flat),
paroxysmal nocturnal dyspnea (sudden
onset of breathlessness at night),
edema, or leg swelling.
 It also includes questions about results
of past electrocardiograms or other
cardiovascular tests.
 Gastrointestinal System

 This review involves questions about abdominal pain,

bloating, nausea, vomiting, diarrhea, constipation, changes
in bowel habits, gastrointestinal bleeding, or difficulty
swallowing
 Peripheral vascular system
 The peripheral vascular system is composed of arteries,
veins, and lymphatics.
 It plays a key role in the development of heart disease,
one of the leading causes of death.
 It involves questions about intermittent claudication; leg
cramps; varicose veins; past clots in the veins; swelling in
calves, legs, or feet; colour change in fingertips or toes
during cold weather; swelling with redness or tenderness.
 Urinary System
 The urinary system is composed of the kidneys, ureters,
bladder, and urethra.
 The review involves questions about frequency of
urination, polyuria, nocturia, urgency, burning or pain
during urination, hematuria, urinary infections, kidney or
flank pain, kidney stones, ureteral colic, suprapubic pain,
incontinence; in males, reduced caliber or force of the
urinary stream, hesitancy, dribbling
 Reproductive System
 For males, review involves questions about hernias,
discharge from or sores on the penis, testicular pain or
masses, scrotal pain or swelling, history of sexually
transmitted diseases and their treatments.
 Sexual habits, interest, function, satisfaction, birth control
methods, condom use, and problems.
 Concerns about HIV infection.
 Human Papillomavirus infection or vaccine (HPV).
 Reproductive System
 For females, it involves questions about age at
menarche; regularity, frequency, and duration of
periods; amount of bleeding; bleeding between
periods or after intercourse; date of last menstrual
period; dysmenorrhea; premenstrual tension.
 Age at menopause, menopausal symptoms,
postmenopausal bleeding.
 Vaginal discharge, itching, sores, lumps, sexually
transmitted diseases and treatments.
 Reproductive System
 Number of pregnancies, number and type of
deliveries, number of abortions (spontaneous and
induced), complications of pregnancy, birth control
methods.
 Sexual preference, interest, function, satisfaction, any
problems, including dyspareunia.
 HIV & HPV.
 Musculoskeletal system

 The musculoskeletal review covers joint pain,

stiffness, swelling, limitation of movement, muscle
weakness, or deformities.
 It helps to assess for arthritis, injuries, or other
musculoskeletal disorders.
 Neurological

 This review involves questions about headaches,

dizziness, syncope (fainting), seizures, weakness,
numbness, tingling, coordination problems, changes
in speech or vision, memory loss, or changes in mood
or behavior.
 Psychiatric

 The psychiatric review covers symptoms such as

anxiety, depression, mood swings, changes in sleep
patterns, appetite changes, concentration difficulties,
or suicidal thoughts.
 Endocrine

 This review includes questions about heat or cold

intolerance, excessive sweating, polyuria (excessive
urination), polydipsia (excessive thirst), changes in
weight, appetite changes, or symptoms of
hyperthyroidism or hypothyroidism.
 Hematologic

 The hematologic review involves questions about easy

bruising, bleeding gums, petechiae, signs of anemia or
bleeding disorders
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Functional Health
Patterns
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