mental health nursing history collection

1. Mrs. Melba Sahaya Sweety.D
GIMSAR
PSYCHIATRIC
HISTORY
TAKING

2. DEFINITION
• The psychiatry history is the
record of the patient’s life; it
allows a psychiatrist to
understand who the patient is
,where the patient has come
from ,and where the patient is
likely to go in the future.

3. IMPORTANCE
• Obtaining a comprehensive
history from a patient and if
necessary from, from informed
sources are essential to make a
correct diagnosis and
formulating a specific and
effective treatment plan.

4. PURPOSE
• To describe adaptive and
maladaptive behaviour.
• To formulate priorities.
• To identify problems.
• To predict probable responses to
potential interventions.
• To analyze the client’s perceptions.
Helps to develop nursing care plan.

5. BASIC PRINCIPLES
OF HISTORY TAKING
• Introduce yourself
• Explain the purpose and
approx how long it will take
• Ask Open Ended Questions
• Allow the patient to Explain
Things In his/her Own
Words

6. BASIC PRINCIPLES OF
HISTORY TAKING
• Encourage the patient to
Elaborate and explain
• Avoid Interrupting
• Guide the Interview As
Necessary
• Avoid Asking “Why?” Questions
• Listen and Observe For Cues
• You might need an informant

7. COMPONENTS
1. Identification data
2. Informants
3. Chief complaints
4. H/o Present Illness
5. Treatment history
6. Past history of illness
– a) Medical/surgical illness
– b) Past psychiatric history
7 Family history

8. Components
8. Personal history
a. Perinatal history
b. Childhood history
c. Educational history
d. Play history
e. Emotional problems during adolescence
f. Puberty
g. Obstetrical history
h. Occupational history
i. Sexual and marital history
j. Premorbid personality

9. I. Identification data
• Name :
• Age :
• Sex :
• Marital status:
• Religion:
• Education:
• Occupation :
• Occupation :
• Income Address:
• Date of
admission:
• Hospital No :
• Psychiatric ward
:
• marital status
• Identification
Marks

10. I. Identification data

11. I. Identification data

12. I. Identification data

13. II INFORMANTS
• The sources of the information:
• Informant’s name
• The reliability of the sources
• Relation to Patient:
• Intimacy with the patient
• Interest of the patient’
• Does the Informant live with the patient?
• Duration of stay with the patient
• Intellectual and observational ability

14. III CHIEF COMPLAINTS ON
ADMISSION
• Presenting complaints and/or
reasons for consultation should be
recorded.
• Both the patient’s and the
informant’s version should be
recorded separately it should be
recorded even if the patient is unable
to speak and the patient explanation
regardless of how bizarre or
irrelevant

15. Chief complaints
on admission
• Patient's problem or reason for
the visit Recorded as the
patient's own words
• Ask leading questions such as
-"What brings you here today?“
-How can I help you?”

16. • Examples:
• ”am having thoughts of
wanting to harm myself”
• “peoples are trying to drive
me insane”
• “I feel am going mad”
• “am angry all the time “

17. PRESENT ILLNESS
• HISTORY OF PRESENT ILLNESS
• Provides a comprehensive and
chronological picture of the
events. Probably the most
helpful in making an accurate
diagnosis.

18. History of present illness
Duration- Weeks/months/years
Mode of onset-Abrupt/acute/sub
acute/Insidious
Course-( continuous / episodic/
fluctuating/ deteriorating/ improving/
unclear)
Precipitating factors (death/ separation/
loss/ frightening experience/ any other)
Aggravating and relieving factors, if any.

19. History of present illness

20. History of present illness

21. History of present illness

22. History of present illness

23. HISTORY OF PRESENT
ILLNESS
• When the patient was well the last time
should be noted.
• The time of onset
• When the symptoms are first noticed by the
patient or by the relatives.
• The symptoms of the illness from the
earliest time at which a change was noticed
until the present time should be narrated
chronologically, in a coherent manner.

24. HISTORY OF PRESENT
ILLNESS
• The presenting chief complaints should be
expanded.
• Any disturbances in the physiological
functions like sleep, appetite, and sexual
functioning
• Always enquire about suicidal ideation
• Important negative history should be
recorded(eg. no h/o head injury)

25. TREATMENT HISTORY
• Drugs- dose/route/side effects/complains
• ECT
• Psychotherapy
• Rehabilitation Year & Month Centre
Duration Treatment
• Current medications
– • What medications do you take regularly and
since when?
– • What medications have you had in the past?

26. PAST HISTORY
• PAST HISTORY OF
ILLNESS
– a) Past medical/surgical
illness:
– b)Past psychiatric history

27. Past medical/surgical illness:
• History of chronic medical illness
and details of medication received
and the duration of illness
– Hospitalization
– Medical/neurological/surgical
illness
– Head injury/ convulsion/
Unconsciousness
– Accidents/surgical procedure
– DM/HTN/CAD/Visceral/ HIV +ve

28. Past psychiatric
history
• Past psychiatric history
• Past psychiatric illness
• H/o alcohol/substance
abuse/dependence

29. Past psychiatric history
• –Had the patient suffered from any mental
illness and undergone psychiatric treatment
• –Has the patient been hospitalized earlier for
the treatment of mental illness
• –What was the nature of treatment she or he
had been getting; drugs or ECT
• –Did the patient improve with the treatment

30. EXAMPLE
• Any similar or other psychiatric
problems in the past?
• Have you ever been admitted to a
psychiatric hospital?
• What treatments have you had?
• Has there ever been a time that
you felt completely well?

31. VII FAMILY HISTORY
• a. Family structure
• b. Family history of illness
o Psychiatric illness-
similar/other
o Major medical illness
o Alcohol/drug
dependence/suicidal attempt

32. • Current social situation
• Home circumstances
• Per capita income
• Socioeconomic status
• Head of the family-nominal &
functional
• Current attitude of the family members
towards the patient’s illness
• Communication pattern in the family
• Cultural &religious values
• Social support system available

33. • S. no name age sex
relationship with patient
age/ mode of death
Description of family
members

34. • Are your parents still living? Are
they well? • Do you mind me
asking how they died?
• What did your parents do?
• Do you have any brothers or
sisters? Are you close to them?
• As far as you know, has anyone in
your family ever had problems with
their mental health?

35. Genogram symbols

36. Genogram symbols

37. Genogram symbols

38. Genogram symbols

39. Genogram symbols

40. IV Personal history
• a. Perinatal history
• Antinatal
• Any febrile illness
• Physical/Psychiatric illness
Medications/drugs/alcohol use
• Trauma to abdomen
• Immunization
• Intranatal
• Full term/premature/postmature
Wanted/unwanted

41. • Delivery
Normal/instrumental/
ceserean Birth cry
Immediate/delayed
• Birth defects
• Postnatal complications
Cyanosis/convulsion/jaundi
ce
• Any other

42. • b. Childhood history
–Primary care giver Whether
the patient was brought up by
mother/some one else
Feeding Breast feed/artificial
–Age at weaning
–Developmental milestones
Normal/delayed
–Age & ease of toilet training

43. –Behavioural and emotional
problems
–Thumb – sucking
– temper tantrums
– tics, head-banging
– night terror
–fears
– bed-wetting
–nail-biting.
–Stuttering/stammering
–Enuresis/ encopresis
–Somnambulism

44. • Where were you born?
• Where did you grow up?
• As far as you know, was your
mother’s pregnancy and delivery
normal?
• If not, were there any problems
around the time of your birth?
• Did you have any serious illnesses
as a young child?
• Were you walking and talking at
the correct times?

45. c. Educational history
–Age at beginning & finishing formal
education ,Academic and extra
curricular achievements- if any
–Relationship with peers &teachers
–School phobia
–Truancy, non-attendance
–Learning disabilities
– Reason for termination of studies(if
occurs prematurely)

46. • Which school/s did you go to?
• Did you enjoy school?
• Any lasting memories of school?
• Did you have many friends at
school? Still in contact?
• When did you finish school ?
Qualifications? • Were you ever
in trouble at school? ever
expelled or suspended? Bullied?

47. • d. Play history
– Games played At what age
&with whom Relationships
with playmates
e. Emotional problems
during adolescence
Running away from home
delinquency smoking drug
use any other

48. • f. Puberty
• Age at appearance of secondary
sexual characteristics
• Anxiety related to puberty changes
• Age at menarche
• Reaction to menarche
• Regularities of cycle & duration of
flow
• Abnormalities if any(menorrhagia
/dysmenorrhea)

49. • g. Obstetrical history
– LMP
–Any abnormalities associated
with pregnancy/ delivery/
puerperium
–Number of children
–Termination of pregnancy
– Reaction to menopause

50. • h. Occupational history
–Age at starting work
– Jobs held in chronological order
– Reasons for change, if any
–Current job satisfaction (including
relationship with authorities ,peers
and if applicable ,subordinates).
– Whether job is appropriate to
client’s back ground

51. • i. Sexual and marital
history
• Type of marriage: self choice/
arranged
• Duration of marriage
• Interpersonal relationship with
in-laws: satisfactory/
unsatisfactory
• Details of spouse and children

52. • J. Premorbid personality
• a. Interpersonal relationships
– Interpersonal relationship with family
members, friends, work-mates and
superiors
– Introverted/extraverted
– ease of making and keeping social relations.
– Use of leisure time
• Hobbies
• Interests
• Intellectual activities
• energetic/sedentary.

53. • Predominant mood
– Optimistic/pessimistic
– Stable/prone to anxiety
– Cheerful/despondent
– Reaction to stressful life events.
• Attitude to self & others
• Self-confidence level
• self-criticism & self-consciousness
• selfish/thoughtful of others
• self-appraisal of abilities,
• achievements and failures.
• General attitude towards others

54. a. Attitude to work and responsibilities
b. Decision making
c. acceptance of responsibility
d. flexibility
e. foresight.
f. Religious beliefs and moral attitudes
g. Fantasy life Day dreams –frequency
and contents

55. •Habits
• Eating pattern: regular/
irregular
• Elimination: regular/
irregular
• Sleep: regular/ irregular
• Use of
drugs/alcohol/tobacco

56. J. Premorbid personality

57. J. Premorbid personality

58. J. Premorbid personality

59. THANK U