History Collection
Introduction
Assessment of the client need is an essential component in psychiatry to assess
the needs, pattern of illness and aggravating factors. Sound base of patient’s
history provides the base of effective delivery of health care services and
further evaluation of progress.
Purposes:
* Understand the healthy
and unhealthy lifestyle
behavior.
* Identify problems
associated with mental health.
* To identify the priority
needs to be met.
* Predict responses to
potential
interventions.
* Analyze the client’s
perceptions.
* Helps to develop nursing
care plan.
* Identify psychiatric
emergencies.
Points to be kept in mind
* Maintain good rapport.
* Confidentiality of
information
* Allow the patient to tell
the stories in their own words in the order that they consider most important.
* The patient’s behaviour should
be noted and reactions should be observed and should later be recorded in
general behaviour.
* The patient’s history
should be supplemented by information from a close relative.
* Objective and subjective
data should not be mixed up
* Should be recorded
systematically
* Flexibility should be
maintained if the patient feels uncomfortable.
* Facts should be included
rather than technical terms
* The examiners
observations conclusions and summaries should be recorded as well.
1. Patient profile
· Name :
· Hospital No :
· Psychiatric No :
· Age :
· Gender :
· Religion:
· Marital status:
· Education:
· Occupation :
· Mother Tongue :
· Area of residence:
· Date and time of admission:
· Ward and bed no:
· Diagnosis :
· Informant’s name:
* Relation to the patient
* Reliability of
informant’s information
2. Chief complaints on admission:
* Patient says
* Informant says
The chief complaint in the patient’s and
informant’s own words states why he or she has come or been brought for help.
It should be recorded even if the patient is unable to speak and the patient
explanation, regardless of how bizarre or irrelevant. Chief complaints include
the issues the client suffers at the present. The chief complaints should be
obtained from the client and the patient relative. It should with the duration
of each complaint.
3. History of present illness
It includes presenting signs and symptoms, mode of onset, duration, progress,
aggravating and relieving factors and the treatment taken.
4. History of past Psychiatry illness
It includes diagnosis, treatment, hospitalization, duration of
illness, degree of compliance, history of consultations with other systems of
medicine, alcohol or other substance abuse., suicide attempt. In case of
alcoholic patients amount, brand and year of starting drinking should be collected.
5. Family history
There is a strong
relationship with the spread of mental illness and family members. The mental
health depends on the adjustment and living situations of the
family members a good support system is essential to maintain a good mental
health among the family members. Should identify the type of family, number of
members in the family, any history of mental illness among the family members,
and consanguinity of the parents.
Also include the father’s and mother’s life history and
their attitude towards the client. The family history should contain a family
tree showing the hierarchical distribution of the members. Burden of any
physical illness in the family or presence of stressors also should be elicited.
Family tree in diagrammatic representation should be made for easy
understanding.
1. Socio-Economic History
Should evaluate for the support system
available. Their relationship with the neighbours, involvement in social
activities, the source of income and monthly income.
2. Nearest Health Care Facilities.
Include the PHC/ clinics/ hospitals/ others
3. Personal history
* Prenatal and Perinatal
History:
· Where the patient was born and whether the
patient was planned and wanted?
· Were there any problems with the mother’s
pregnancy and delivery?
· What was the mother’s emotional and physical
state at the time of patient’s birth?
· Were there any maternal health problems during
pregnancy?
· Was the mother abusing substances or drug during
pregnancy?
* Early childhood
Mother and infant develop a bond as soon as the
neonate is born. The interaction and the relationship of the family members
play an important role in shaping the attitude and to enhance the mental health
of the child. Negligence from the mother’s part can cause the child to suffer
from mental illnes.
· Mother – child
interaction during feeding and toilet training.
· Play habit:
Q) when did the child started to play and who all
were included in the play time?
Alone, with others or not at all.
· Feeding habit :
Q) Whether the child was breast fed and for how
many months?
Breast fed or bottle fed, eating problems.
· Early development-
Q) When did the child started to walk and
talk?
walking, talking, teething, language development,
motor development, sleeps pattern, stranger anxiety, maternal deprivation.
· Toilet Training – Age, attitude of parents, feelings about it.
· Symptoms of behavior
problems-
Q) did the child showed any behaviours that
indicated mental illness
Thumb – sucking, temper tantrums, tics, head-bumping,
night terrors, fears, bed-wetting, and nail-biting.
Personality as a child: Whether the child was shy, restless,
overactive, withdrawn, outgoing, timid, friendly, patterns of play.
* Middle childhood(3-11yrs)
Middle childhood brings many changes in a
child’s life. By this time, children can dress themselves, catch a ball more
easily using only their hands, and tie their shoes. Having independence from
family becomes more important now. Events such as starting school bring
children this age into regular contact with the larger world. Friendships
become more and more important. Physical, social, and mental skills develop
quickly at this time. This is a critical time for children to develop
confidence in all areas of life, such as through friends, schoolwork, and
sports. This is an important time for children to gain a sense of
responsibility along with their growing independence. Also, physical changes of
puberty might be showing by now, especially for girls. Another big change
children need to prepare for during this time is starting middle or junior high
school.
The things to be looking for
· Early school experiences
· Separations anxiety
· Numbers of friends
· Leader or follower
· Play
· Relationship to teachers and peers
· Any complaints from teachers to class mates
· Involvement in extracurricular activities
· Impulsiveness
· Aggression
· Passivity
· Antisocial behaviour
* Late childhood
This is a time of many physical,
mental, emotional, and social changes. Hormones change as puberty begins. Most
boys grow facial and pubic hair and their voices deepen. Most girls grow pubic
hair and breasts, and start their period. They might be worried about these
changes and how they are looked at by others. This also will be a time when
your teen might face peer pressure to use alcohol, tobacco products, and drugs,
and to have sex. Other challenges can be eating disorders, depression, and
family problems. At this age, teens make more of their own choices about
friends, sports, studying, and school. They become more independent, with their
own personality and interests.
Social relationship
· Attitudes towards siblings and playmates, number
and closeness of friends.
· Leader or follower, social popularity,
participation in group or gang activities idealized figures, patterns of
aggression, anxiety.
· Antisocial behavior child.
> School History:
- Adjustment with schools
- Interest in studies
- Sports .
> Cognitive and
motor development:
- Reading skills, writing skills etc.
> Emotional
and physical problems
Nightmares, phobias, bed-wetting, running
away, smoking ,alcohol or other substance abuse ,suicidal thoughts and acts.
Sexuality:
- Early curiosity
- Acquisition of sexual
knowledge ,sexual abuse
- Onset of puberty and
feelings about it
- Adolescent sexual activity
- Attitude towards opposite
sex
- Sexual practices
- Sexual orientation
- Menstrual history: age at
menarche and preparation/duration and frequency/LMP/any irregularities
* Adulthood history
Occupational History:
- Age at the time of
starting to work
- Choice of occupation
- Satisfaction with job
- Any work related conflicts
-Relationship with peers
& authorities
- Subordinates
- Job changes
Marital and Relationship History:
- History of marriage
- Relationship with spouse,
in-laws & children ,sexual life etc
Education History:
The educational history provides clues about the patient’s social
and cultural background, intelligence, motivation and any obstacles to
achievement.
- What was the
highest grade or graduate level attained?
- What did the
patient like to study and what was the level of academic performance? What is
the patient’s attitude towards academic achievements?
Religion
- The history of religious
background of both parents and the details of patient’s religious instruction
should be taken.
- The interviewer should
trace the evolution of the patient’s adolescent religious practice to present
beliefs and activities.
- What the patient’s
religious say about the treatment of psychiatric or medical illness?
Legal history
- Has the patient even been
arrested and if so for what?
- How many times?
- Was the patient ever in
jail?
- For how long?
- What is the patient’s
attitude towards the arrests or prison terms?
Premorbid personality
This section probes
into the patient's personality and day to day functioning before the onset of
the illness. The history so far should have already given you some idea about
this. It may be that due to the chronic nature of the illness the patient can’t
recall how they were before becoming ill
- Social relations
- Attitude to work and
responsibility
- Leisure activities and
interest
- Reaction to stress.
Dreams, fantasies & Values : If any nightmares, any day dreams, fantasies
Immunization history:
For children
Activities of daily living:
· Personal hygiene
· Eating pattern :type of diet ,number of meals per
day, preferences
· Sleeping pattern and rest
· Activity and exercise :Daily walking /any other,
Nature of work (sedentary /mild /moderate /heavy)
· Habits and hobbies
· Elimination :Bowel and bladder
Conclusion
Adequate findings from the history will help in formulating the accurate
diagnosis and effective treatment. As a health team member nurse in psychiatric
setting must be thorough with the components to be measured and the data to be
collected.
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