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.
* 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 :
· Marital status:
· 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
· Relationship to teachers and peers
· Any complaints from teachers to class mates
· Involvement in extracurricular activities
· 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.
· 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.
– 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
– Age at the time of starting to work
– Choice of occupation
– Satisfaction with job
– Any work related conflicts
-Relationship with peers & authorities
– Job changes
Marital and Relationship History:
– History of marriage
– Relationship with spouse, in-laws & children ,sexual life etc
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?
– 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?
– 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?
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
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
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.