history collection- psychiatric nursing

1. MS. NAYANA D. SHINDE
M.SC NURSING
(MENTAL HEALTH NURSING)
HISTORY
COLLECTION

2. PSYCHIATRIC NURSING
• It is specialized area of nursing practice
which deals with diagnosis and treatment
of mental health problems.

3. COMPONENTS
Identification data
Informants
Reliability of information
Presenting (Chief) complaints
History of present illness(HOPI)
Past psychiatric and medical history
Treatment history
Family history
Personal history
Premorbid history
Conclusion

4.  IDENTIFICATION DATA
• Name:- (Alias name and pet name)
• Age/gender:-
• Marital status:-
• Education:-
• Occupation:-
• Income:-
• Residential address:-
• Religion:-
• Identification mark:-
• Source of referral:-
• DOA:-

5. INFORMANTS
• Informants are the people who provide information
about patient.
• Patients
mother/father/wife/husband/son/daughter
• Patients file
• Patient self

6. RELIABILITY OF INFORMATION
• Reliability of information has 4 parameters
Relationship with patient
Intellectual and observational ability
Familiarity and length of stay with patient
Degree of concern regarding patient

7. CHIEF COMPLAINTS
• It should be recorded on the basis of onset,
duration and symptoms under following points
Patients version
Informants version

8. HOPI
(HISTORY OF PRESENT ILLNESS)
• It should be written under following points
When the patient was last well or asymptomatic
should be clearly noted
Time of onset
Symptoms of illness with duration
Life chart

9. •LIFECHART

10. PAST PSYCHIATRIC HISTORY
It includes
• Any history of past psychiatric illness
• Past history of psychotropic medication
• History of drug or alcohol abuse
• History of serious medical, neurological illness or
accidents, febrile convulsions and nature of
treatment received

11. TREATMENT HISTORY
• Any treatment received
• History of treatment adherence
• Response to treatment
• Any adverse effects
• Any drug allergies

12. FAMILY HISTORY
• Family history is usually recorded under following
headings
Family structure/family tree/pedigree chart
Family history of psychiatric illness or alcohol
abuse
Current social situation

14. PERSONAL HISTORY
• PERINATAL HISTORY-
• Difficulties in pregnancy, febrile illness,
drugs/alcohol use, abdominal trauma should be
asked.
• Whether the patient was a wanted or unwanted
child, whether delivery was normal, any
instrumental delivery, where
born(home/hospital),APGAR score, birth
cry(immediate/delayed), birth defect, TORCH
infection.

15. • CHILDHOOD HISTORY
• Whether the patient was brought up by mother or
someone else, breastfeeding, when weaning
started, age and ease of toilet training, any delay in
the developmental milestone, any occurrence of
neurotic traits (stammering, tics, enuresis,
encopresis, night terrors, thumb sucking, nail biting,
somanambulism,etc)

16. • EDUCATIONAL HISTORY
• Age of beginning and finishing formal education,
academic achievements, relationships with peers
and teachers, reason for termination of studies
should be asked

17. • PLAY HISTORY
• What games were played at what stage, with whom
and where, relationships with peers, type of
play(solo/group) should be recorded.

18. • PUBERTY
• Age of menarche and reaction to menarche (in
females), age at appearance of secondary sexual
characteristics (in both female and male),
masturbation.

19. • MENSTRUAL AND OBSTETRICAL HISTORY
• Regularity and duration of menses, length of each
cycle, no. of children, termination of pregnancy(if
any) should be asked.

20. • OCCUPATIONAL HISTORY
• Age at starting work, reasons for changes,
ambitious, relationships with authorities, peers and
subordinate, present income should be asked.

21. • SEXUAL AND MARITAL HISTORY
• What kind of masturbation(fantasy and activity), sex
play(if any), any gender identity disorder, duration of
marriage, arranged/love marriage, no. of marriages,
divorce/ separation.

22. PREMORBID PERSONALITY(PMP)
(It is prior to onset of disease)
• The following subheadings are used for premorbid personality
 Interpersonal relationship- with family members, friends and
colleagues.
 Use of leisure time- hobbies, interests
 Pre-dominant mood- optimistic/ pessimistic, cheerful, reaction to
stressful events
 Attitude to self and others- self confident, self criticism, self
conscious, self centered
 Attitude to work and responsibility
 Religious beliefs
 Fantasy life- sexual fantasy/ day dreaming
 Habits