The terms art and science are significant for the practice of nursing.

These two concepts have a particular meaning and their defining char acteristics help to illuminate the nature of nursing practice. An under standing of each term is foundational to the comprehension of similari ties and differences and to an understanding of the complex relation played out in nursing practice. Nursing as an art form has three major componentsmedium, process, and product. The science consists of the systematized knowledge. Both nursing's art and its science are essential for excellence in the performance of nursing's mission. There is a delicately balanced movement between art and science portrayed by experienced nurses that transcends as it uses the differences between these two forms. Goals & Objectives History TakingChapter Goal Upon completion of this chapter, nurse will be able to use the appropriate techniques to obtain a medical history from a patient. Cognitive Objectives As anurse you should be able to do the following:

Describe the techniques of history taking. Discuss the importance of using open and closed ended questions. Describe the use of facilitation, reflection, clarification, empathetic responses, confrontation, and interpretation. Differentiate between facilitation, reflection, clarification, sympathetic responses, confrontation, and interpretation. Describe the structure and purpose of a health history. Describe how to obtain a health history. List the components of a history of an adult patient.

Affective Objectives As a nurse you should be able to do the following:

Demonstrate the importance of empathy when obtaining a health history. Demonstrate the importance of confidentiality when obtaining a health history. HEALTH HISTORY FORMAT

BIOGRAPHICAL DATA Name, age, gender, family/marital status, religion, Date, address, occupation, HEALTH INSURANCE Referral source, informant (reliability) (document)

CHIEF COMPLAINT: Brief, 1-2 symptoms & duration, PRESENT ILLNESS/PROBLEM: Or Current Health Status PI: Illness or focused history Initial wellness history Interval history PI: Analysis of a Symptom Onset Characteristics Course since onset When: Last well: Onset, duration & chronologic sequence of symptoms What: Quality, intensity, related symptoms Where: Location, range of symptoms How: Associated factors, communicable exposure Why: Possible solutions, Rx, (aggravating/alleviating)

ALTERNATIVE METHODS FOR PRESENT ILLNESS: PI PI: BATES Location Quality

Quantity of severity Timing (onset, duration, frequency) Setting in which symptoms occur Factors that aggravate or relieve Associated manifestations

PI: OLD CART O Onset L Location D Duration C Causative factors A Associations R Reactions to what has been tried T - Treatment PAST MEDICAL HISTORY General health & strength Major childhood & adult illnesses Immunizations & dates: reactions to immunizationsSurgery: Dates, Hospital, Dx., Complications Injuries: Resulting disability Medical-legal relationships Medications: Current, past month, past: Rx. & OTC, herbs, alternative therapies Allergies: Meds, environmental, food. Must include "kind of" reaction Transfusions: Reactions, date & # of units if known Emotional status: Mood disorders, psychiatric attention

FAMILY HX

Any family members with patient's illness Age of parents: Age & cause of death if deceased Age & # of siblings: Health Status Hx of heart disease, hypertension, cancer, TB, diabetes, asthma, STD's, kidney, thyroid disease Major genetic disorders & health problems: GENOGRAM TO GRANDPARENTS PERSONAL & PSYCHOSOCIAL HX Personal status: Birthplace, socioeconomic group, general life satisfaction, interests, Habits: Diet, sleeping, exercise, coffee, alcohol, drugs, tobacco Sexual Hx: Satisfaction/concerns Home conditions: Housing, economic conditions, safety Occupation: Work & conditions or hazards Environment: Travel, REVIEW OF SYSTEMS: ROS GENERAL: Fever, chills, sweats, weight changes, weakness, fatigue, heat/cold intolerance, bleeding, radiation SKIN, HAIR, NAILS: Rashes, lumps, sores, itching, color or texture changes, bruising, abnormal growths HEAD: Headaches, injury, dizziness, syncope, LOC, stroke EYES: Vision/correction, blurring, diplopia, eye meds, trauma, redness, pain, glaucoma, cataracts EARS: Hearing/loss, pain, discharge, infection, tinnitus, vertigo/"dizziness" NOSE: Smell, obstruction, injury, epistaxis, discharge, colds, allergies, sinus pain MOUTH & THROAT: Hoarseness, sore throats, gum problems, tooth abcess, dental care, sore tongue, taste NECK: Lumps, "swollen glands," goiter, pain/stiffness sources of stress

LYMPH NODES: Enlargement, tenderness, RESPIRATORY: Pain, dyspnea, SOB, cyanosis, wheezing, cough, sputum (color & quantity), asthma, bronchitis, emphysema, pneumonia, TB/BCG, last CXR & results, smoking CARDIOVASCULAR: Chest pain/distress, palpitations, SOB, dyspnea, orthopnea (pillows needed), paroxysmal nocturnal dyspnea, MI, rheumatic fever, murmur, exercise tolerance, ECG or other cardiac tests, hypertension, edema, leg pains/edema/coolness/hair loss, varicose veins, thrombosis, ulcers GASTROINTESTINAL: Appetite, digestion intolerance, heartburn, N&V, hematomesis, bowel irregularity, stool appearance, flatulence\ , hemorrhoids, jaundice, ulcer, gallstones, abdominal enlargement, previous X-ray ENDOCRINE: Thyroid enlargement/tenderness, heat/cold intolerance, unexplained weight change, diabetes S/S, MALE REPRODUCTIVE: Puberty onset, erections, , testicular pain or masses, hernias, lesions/discharges, , sexual activity, , infertility, prostate, STDs, STE FEMALE REPRODUCTIVE: Menses: Menarche, regularity, duration & amt. of flow, dysmenorrhea, LMP, last Pap AND RESULTS, sexual activity, , contraception, fertility, menopause, discharge, itching, sores, STDs Gravida/para: , preg. duration, antepartum problems BREAST: Pain, tenderness, discharge, lumps, galactorrhea, mammogram AND RESULTS, SBE GENITOURINARY: Dysuria, pain, frequency, urgency, nocturia, hematuria, stress incontinence, hernias, STDs MUSCULOSKELETAL: Joint stiffness, pain, motion restriction, weakness, paresthesias, cramps, deformities, back problems HEMATOLOGIC: Anemia, lymph swelling, bruising/petechiae, fatigue, blood , transfusion, radiation NEUROLOGIC: CNS disease, syncope, blackouts, dizziness, numbness, tingling, seizures, weakness/paralysis, tremors head injury coordination, memory, cognition, headaches,

PSYCHIATRIC: Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances CONCLUDING QUESTIONS: "Is there anything else that you think would be important for me to know?" ANALYSIS OF DATA Identify abnormal findings Cluster findings into logical groups Localize findings anatomically Localize findings into probable process: Pathological such as inflammatory, metabolic, degenerative Pathophysiological mal functioning, such as congestive heart failure Psychopathological behavioral, mood disorder, thought process disturbance Construct a working hypothesis from the central findings Match the findings with all causative conditions you know could as associated Eliminate hypothesis that fail to explain the findings Weight the probabilities & select the most likely diagnosis Consider life-threatening & treatable situations Test the hypothesis or obtain further studies Establish a working definition of the problem

DOCUMENTAION OF DATA Permanent medicolegal record of the patients health status & treatment Record pertinent postive findings abnormal findings Record pertinent negative findings normal findings, or absence of abnormal findings

PHYSICAL EXAMINATION Inspection Palpation Percussion Auscultation Measurements

INSPECTION PALPATION Light palpation gentle pressure, 1 cm or to inches deep Deep palpation may use bimanual methods, 4 cms or 1.5 to 2 inches deep Palpate tender areas last Palmar area of hand & fingers, is discriminatory for touch Ulnar area of hand, is discriminatory for touch Dorsal area of hand, is discriminatory for temperature Observe for wellness illness condition of the patient Identify degree of distress Look before you touch Provide comfortable, private conditions Provide adequate direct lighting

PERCUSSION SOUNDS HEARD Tympany: Hyperresonance: Resonance: Dullness: Flattness: AUSCULATATION Gastric bubble Emphysematous lung Healthy lung Liver Muscle

Listening to sounds of lungs, heart, blood vessels & abdominal viscera Ear Stethoscope Diaphram is held firmly to the skin, detects high frequency sounds Bell is held with light pressure, detects low frequency sounds ANTHROPOMETRIC MEASUREMENTS & VITAL SIGN SELECTIONS: Will be discussed in the following section Height Weight Circumferences: Head, Chest, Abdomen, Extremities Temperature, Pulse, Respiration & Blood Pressure Vison & hearing screening Jugular Venous Distention Body Mass Index Skin fold thickness Mid-upper arm circumfer

Historical information often comes from a variety of sources, including: 1 The patient 2 The family 3 Friends 4 Police officers 5 Other observers Factors that affect the quality of historical information include: 1 Mental status (e.g., possible intoxication) 2 Memory, trust (e.g., in a drug overdose or crime scene injury) 3 Motivation (e.g., does the patient have a reason for secondary gain Essential Components of a Medical History 1 2 3 4 5 6 7 8 9 10 11 Regardless of the event, the history must contain certain basic information, including: Date Identifying dataage, sex, race Chief complaint (CC) History of the present illness (HPI) Past medical history (PMHx) Current health status Current health status includes: Current medications Allergies Tobacco use

12 Alcohol, drugs, and related substancesDiet 13 Screening tests Essential Components of a Medical History Current health status (cont.): 1 Immunizations 2 Sleep patterns 3 Exercise and leisure activities 4 Environmental hazards 5 Use of safety measures 6 Family history Essential Components of a Medical History Current health status (cont.): 1 2 3 4 5 Home situation (including pets, spouse, or significant others) Daily life Important experiences Religious beliefs Patients outlook on life overall

Essential Components of a Medical HistoryCurrent Health Status Depending on the circumstances, obtaining all information on currenthealth status may not be possible or even appropriate. 1 At a minimum, you should always strive to find a history of: 2 Allergies 3 Use of medications (with or without a prescription; including herbals and over-the-counter preparations) 4 Use of drugs, alcohol, or tobacco Techniques of History TakingSetting the Stage Environment 1 Proper environment enhances communication between you and the patient. 2 Often, the prehospital setting does not lend itself to an ideal history-taking atmosphere. 3 You may be more successful by placing the patient into the ambulance after a brief evaluation and continuing the interview there. 4 Respect the other person's personal space by not getting closer than 2 to 3 feet, unless medically necessary, during the initial interview. 5 Shaking hands is a good technique to calm the patient, as well as to initially evaluate skin temperature, moisture, and strength. Techniques of History TakingSetting the Stage 1 Your demeanor and appearance 2 Just as you are watching the patient, the patient and bystanders will be watching you. 3 The majority of our interpersonal communication occurs not by words, but rather by "body language." 4 A clean, neat, and professional appearance will go a long way. 5 Always treat people with respect regardless of the patient's presenting condition. 6 Where possible, refer to the patient by name. 7 Many individuals are offended by the use of "sir" or "madam." 8 Note taking 9 Especially in an uncontrolled situation, it is difficult to remember all the details. 10 Note taking is generally well accepted by patients and essential for proper documentation. 11 If concerns arise, address them and explain your reasons for taking notes to the patient. 12 Do not divert your attention from the patient to take notes, especially when life-threatening problems arise. Techniques of History TakingQuestioning Patients 1 2 3 4 5 6 Ask open-ended questions whenever possible. "Tell me about the pain." "What things change your discomfort?" Closed-ended or direct questions require a simple answer, such as "yes" or "no." "Do you have pain now?" "Does it hurt you to breathe?"

Techniques of History TakingQuestioning Patients Facilitation 1 This is a combination of verbal and nonverbal actions that we use to encourage the patient to say more. 2 It includes posture, actions, or words.

3 4 5

The most helpful method of facilitation often is often making eye contact. Use phrases such as "Go on," "Please continue," or "I am listening" to encourage the patient. Avoid saying "I am listening" when you are obviously doing something else (e.g., looking at equipment).

. Reflection 1 This involves repeating the patient's words (or your summary of them) back to make certain you both are communicating. 2 It encourages additional responses by the patient. 3 Done properly, it does not bias the story or interrupt the patient's train of thought.Example: "What I have heard so far is that you have a heaviness under your breast bone that started a half hour ago and that you have never had anything like it beforeyes?"

Techniques of History TakingQuestioning Patients Clarification 1 Interrupt or ask additional questions to clarify points. 0 At this stage, a few short, directed questions may be appropriate. 1 "Now, you said that breathing makes your pain worse; is this mostly when you breathe in, when you breathe out, or all the time?" 2 Alternatively, you could ask an open-ended question: "Now, you said that breathing made your pain worse; when during your breathing is the pain made worse?

Techniques of History TakingQuestioning Patients 1 2 3 4 5 6 7 8 9 10 Empathetic responses Empathy is very different from sympathy. Though sympathy may be appropriate at some times, your job in history taking is to be professional, kind, and empathetic. Try to identify with what the patient is going through. Express to the patient things such as: "You sound uncomfortable." "I'd probably be frightened if I were in your shoes." Confrontation It is more direct but potentially disruptive to your relationship with the patient. It may be extremely helpful under selected circumstances. Examples: "I'm here to help youif I don't know what drugs you took, I can't do you much good." "I'm not any happier than you are that you hurt your leg; let yourself try to relax some so I can help you out better." Rarely, simply saying something such as "Just do it!" is necessary for the best outcome.

Techniques of History TakingQuestioning Patients Interpretation 1 Interpretation requires you to synthesize what the patient has told you. Verbally and with body language With your own knowledge and "gut feelings" 2 Whether or not you share your interpretation with the patient depends on the circumstances. Example: The patient complains of neck, upper abdomen, and left arm pain. Based on answers to other questions, you suspect a possible heart attack.

Techniques of History TakingHistory of the Present Illness 1 2 3 4 5 6 7 8 Factors that must be evaluated for any symptom include: Location Quality Quantity or severity Duration or timing Onset and setting Aggravating/alleviating factors Associated complaints

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Determine relevant factors in the patient's past medical history,especially those that directly affect the current problem. Preexisting medical problems (e.g., diabetes) or surgeries Medications Allergies Medical care (e.g., family physician) Family history Social history

Techniques of History TakingPast Medical History Social history 1 2 3 4 5 Housing environment Economic status Occupation High-risk behavior Travel history

Techniques of History TakingCurrent Health Status 1 2 3 4 5 6 7 Ask the patient about tobacco use. Determine the use of alcohol, drugs, and other related substances. Note any special diet factors of interest. The "SAMPLE" acronym stands for: SSigns and symptoms AAllergies MMedications PPertinent past medical history LLast oral intake, fluid or solid EEvents leading to the present situation

Techniques of History TakingStandardized Approach to History Taking The acronym "OPQRST" stands for: 1 2 3 4 5 OOnset PProvocation QQuality RRadiationSSeverity TTime

Techniques of History TakingTaking a History on Sensitive Topics Alcohol and drugs Physical abuse or violence Sexual history

Techniques of History TakingTaking a History on Sensitive Topics There is no "cookbook" way for a particular NURto deal with anyparticular patient. 1 Consider the following to provide the best patient care possible: 2 Always remain calm and professional. 3 Appear completely nonjudgmental. 4 Continually remind the patient that you are there to help. 5 Don't be too reassuring, because over-assurance may hamper communication. 6 Remember that the competent patient has the right to refuse to divulge information to you. Special ChallengesSilent Patient A silence is sometimes rather frustrating and confusing. A silent patient often makes us feel uncomfortable. Silence does not necessarily show that the patient is hostile,problematic, or uncooperative. Patients may use silence as a way to collect their thoughts, remember details, or decide whether they trust you.

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