How to take history taking for nurses and midwifery and component of history taking.
Nursing history taking is the process of collecting information of the client. this activity is donned by the Nurse and the primary source of information is client and and second is next kin or medical record.Nursing history taking composed by the 5 important step which are:A. Demographic data
Nursing history taking is the process of collecting information of the client. this activity is donned by the Nurse and the primary source of information is client and and second is next kin or medical record.
Nursing history taking composed by the 5 important step which are:
A. Demographic data
1. Name: Full name of the client.Example: what is your name? My names is john Daniel.2. Date of birth: Age.Example: how are old are? I am 25 year old.3. Gender: you as nurse you have to know the your client or patient gender.Example : are you male or female? Yes am male.4. Marital status: you have to know if is married, divorced, single, widow.Example are you married or single, divorced? Yes am single.5. Occupation: his/her job.Example: what is did you do in every day life? Shop keeper .6. Religion: Religious beliefs.Example : what is you religious? Am catholic christian.7. Ethnicity: Ethnic identity.8. Address: Home address. example : Where do you live?By now am in Rwanda, Provence of Kigali city, kicukiro district, kanombe sector , and busanza village.9. Contact information: Phone number and email address10. Date of admission: for the client who are hospitalized in the health setting you have to know the date of admission.11. Social status : as nurse you have to know how the client live with the purpose of advocating the client when is needed.
B. Chief Complaint.
Reason for seeking care: The main problem or symptom that brought the patient to the healthcare facility.Example : why do you come to the hospital?Am here because I have diarrhea and vomiting last two day and also I have fever , nausea, general body weakness, and dizziness and abdominal pain that why I was here.
C. History of Present Illness.
1. Onset: When did the problem start?Example: when did it start? 2 day ago.2. Location: example: Where is the problem located? In abdominal. Locate that part? And you observe which region of abdomen, on my client he is claiming pain in hypo-gastric located between two inguinal or iliac region.3. Duration: How long has the problem lasted? 40 minutes and also come 5 times per day.4. Character: Describe the quality or nature of the symptom example: your pain is sharp, dull, throbbing? My pain is dull.5. Severity: How intense is the symptom mark you pain is it mild, moderate, severe? My pain is moderate.6. Aggravating factors: example: What makes the symptom worse? When I drink water my pain be come severe.7. Relieving factors: example: What makes the symptom better? When I was lie in prone position.8. Associated symptoms: example: Are there any other symptoms related to the main complaint? Yes as I told you, I have diarrhea and vomiting last two day and also I have fever , nausea, general body weakness, and dizziness and abdominal pain.
D. Past Medical History
A. Allergies: Medications, food, or environmental substancesExample: do you have an allergies? No.B. Illnesses: Previous illnesses or conditions.Example: what are other disease do you have previously?I don’t have other disease.C. Surgeries: History of surgical procedures.D. Hospitalizations: Previous hospital stays.E. Immunizations: Vaccination history.F. Medications: Current medications, including dosage, frequency, and reason for use.G. Health maintenance: Regular check-ups, screenings, and preventive care.
E. Family History.
I. Health status of immediate family members: Parents, siblings, children.II. History of genetic disorders: Known genetic conditions in the family.
1. Name: Full name of the client.
Example: what is your name? My names is john Daniel.
2. Date of birth: Age.
Example: how are old are? I am 25 year old.
3. Gender: you as nurse you have to know the your client or patient gender.
Example : are you male or female? Yes am male.
4. Marital status: you have to know if is married, divorced, single, widow.
Example are you married or single, divorced? Yes am single.
5. Occupation: his/her job.
Example: what is did you do in every day life? Shop keeper .
6. Religion: Religious beliefs.
Example : what is you religious? Am catholic christian.
7. Ethnicity: Ethnic identity.
8. Address: Home address.
example : Where do you live?
By now am in Rwanda, Provence of Kigali city, kicukiro district, kanombe sector , and busanza village.
9. Contact information: Phone number and email address
10. Date of admission: for the client who are hospitalized in the health setting you have to know the date of admission.
11. Social status : as nurse you have to know how the client live with the purpose of advocating the client when is needed.
B. Chief Complaint.
Reason for seeking care: The main problem or symptom that brought the patient to the healthcare facility.
Example : why do you come to the hospital?
Am here because I have diarrhea and vomiting last two day and also I have fever , nausea, general body weakness, and dizziness and abdominal pain that why I was here.
C. History of Present Illness.
1. Onset: When did the problem start?
Example: when did it start? 2 day ago.
2. Location: example: Where is the problem located? In abdominal. Locate that part? And you observe which region of abdomen, on my client he is claiming pain in hypo-gastric located between two inguinal or iliac region.
3. Duration: How long has the problem lasted? 40 minutes and also come 5 times per day.
4. Character: Describe the quality or nature of the symptom example: your pain is sharp, dull, throbbing? My pain is dull.
5. Severity: How intense is the symptom mark you pain is it mild, moderate, severe? My pain is moderate.
6. Aggravating factors: example: What makes the symptom worse? When I drink water my pain be come severe.
7. Relieving factors: example: What makes the symptom better? When I was lie in prone position.
8. Associated symptoms:
example: Are there any other symptoms related to the main complaint? Yes as I told you, I have diarrhea and vomiting last two day and also I have fever , nausea, general body weakness, and dizziness and abdominal pain.
D. Past Medical History
A. Allergies: Medications, food, or environmental substances
Example: do you have an allergies? No.
B. Illnesses: Previous illnesses or conditions.
Example: what are other disease do you have previously?
I don’t have other disease.
C. Surgeries: History of surgical procedures.
D. Hospitalizations: Previous hospital stays.
E. Immunizations: Vaccination history.
F. Medications: Current medications, including dosage, frequency, and reason for use.
G. Health maintenance: Regular check-ups, screenings, and preventive care.
E. Family History.
I. Health status of immediate family members: Parents, siblings, children.
II. History of genetic disorders: Known genetic conditions in the family.