chap 10 history taking

7/30/2019 Chap 10 History Taking

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Chapter 10

History Taking

Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.


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Objectives

Describe purpose of effective history taking inprehospital care

List components of patient history

Outline patient interviewing techniques

Identify strategies to manage challenges in

obtaining a patient history



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Scenario

You are dispatched to a call for abdominal

pain. Your patient is a 41-year-old female

who is having severe right lower quadrant

abdominal pain.



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Discussion

What is the patients chief complaint?

How could your patient history help to determine

the nature of her pain?

Why is it necessary to determine her

medications and allergies?



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History Taking

Information gathered during patient interview

Account of:

Medical and social occurrences in a patients life

Environmental factors that may affect patients

condition

Source of referral

Law enforcement, family, friend, bystander



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Techniques of History Taking

Set the stage:

Provide a safe environment

Your demeanor and appearance

Avoid the patients personal space Inquire about patients feelings

Note taking



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Components of Patient History

Date and time

Identifying data

Source of referral

Source of history

Chief complaint

Present illness

Past history

Current health status

Review of body

systems



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Present Illness

Greeting patient

By name

Shake hands

Avoid unfamiliar or demeaning terms

Patient comfort

Comfort levels

Feelings

Signs of uneasiness



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Opening Questions

Ask why patient is seeking medical care

Use general, open-ended questions

Follow patients lead



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Therapeutic Communication

Facilitation

Reflection

Clarification

Empathy

Confrontation

Interpretation



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Chief Complaint

Symptoms that caused patient to seek care

Often:

Pain

Abnormal function

Change in normal state

Unusual observation made by patient (e.g.,

heart palpitations)



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Chief Complaint

Chief complaint may be misleading

Problem may be more serious than the chief

complaint



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History of Present Illness (HPI)

Identifies the chief complaint

Provides full, clear, chronological account of

symptoms

A thorough HPI:

Asks questions related to chief complaint Interprets patient's response to questions



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OPQRST

Onset of problem

Provocation/Palliative

Quality

Region/Radiation/Referral

Severity

Time



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Significant Past Medical History

General state of health

Childhood illnesses

Adult illnesses

Accidents and injuries Surgeries or hospitalizations

Psychiatric illnesses



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Medications

Medications taken regularly and why

Medication compliance

Nonprescription medications

Herbal remedies

Drugs for recreational purposes



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Last Oral Intake

May affect airway if patient loses consciousness

To determine timing of surgery

To rule out other problems



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Family History

Health of immediate family

High blood pressure, heart disease, contagious

illnesses

Potential for hereditary diseases



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Last Menstrual Period

Women with abdominal pain

If pertinent, also ask about:

Contraceptive use

Venereal disease

Urinary tract infections

Ectopic pregnancy

Vaginal discharge, bleeding



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Last Bowel Movement

Normal or abnormal for patient Diarrhea

Constipation

Bloody bowel movements

Abnormal urinary function Hematuria

Urethral discharge

Pain or burning with urination Frequent urination

Inability to void



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Events Before the Emergency

Obtain information from patient and/or

bystanders

Correlate events with beginning orprogression of illness or injury



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Direct Questions

Direct questions may be required

Should not be leading questions

Ask one question at a time



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Sensitive Topics

Alcohol or drug use

Physical abuse or violence

Sexual issues



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Sensitive Questions Guidelines

Respect patient privacy

Be direct and firm

Avoid confrontation

Be nonjudgmental

Use appropriate language

Document carefully Use patients words when possible



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Special Challenges

Silence

Overly talkative patients

Patients with multiple symptoms

Anxious patients



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Special Challenges

False reassurance

May be tempting

Avoid early reassurance or overreassurance

Unless it can be provided with confidence



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Special Challenges

Anger and hostility Intoxication

Crying

Depression Sexually attractive or seductive patients

Confusing behavior or histories

Limited intelligence Developmental disabilities



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Barriers to Communication

May result from:

Social or cultural differences

Sight, speech, or hearing impairments

Attempt to find assistance to aid in

communication



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Talking with Family and Friends

At scene of an emergency

Good source of information

Helpful when patient cannot provide information

due to illness or injury

If not available, may need to try to locate a

third party to help supply missing data



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Conclusion

Obtaining a patient history provides structure

to the patient assessment and often isessential to establish priorities in patient care.



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Questions?


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