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History taking (Mental health history (Mental health problems may not be…
History taking
Mental health history
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Sadness, hopelessness and crying episode may indicate depression.
Irritability may be the primary affective symptoms of depression or patients may present with cognitive dysfunction.
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Past mental health care including psychotherapy, institutionalization, and electroconvulsive therapy.
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Social history
Nurse should obtain information about patients living arrangements, particularly where and with whom they live, accessibility of their residence and what modes of transportation are available to them .
Nurse should ask about frequency and nature of social contacts, family visits and spiritual or religious participation.
The ability of family to help the patient eg. their employment status, their health, traveling time to the patients home.
The patient attitude towards family members and their attitude toward the patient including their level of interest in helping and willingness to help.
Nurse must ask about frequency and nature of social contacts, family visits and religion or spiritual participation.
Medical history
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Nurse should ask disorders that used to be more common such as rheumatic fever, poliomyelitis and about outdated treatment.
A history of immunizations eg. tetanus, influenza, pneumococcus and adverse reactions to immunizations and skin test results for tuberculosis is needed.
If patients recall having surgery but do not remember the procedure or its purpose. surgical records should be obtained if possible.
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Drug history
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History should include drug used, dose, dosing schedule, drug prescriber, reason for prescribing the drug.
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Marital status
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The number and sex of sex partners are determined, and risk of sexually transmitted disease is evaluated.
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Sensory deficit
Dentures, eyeglasses or hearing aids, if normally worn, should be worn to facilitate communication during the talk.
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Difficulty recalling
Patient may not accurately remember past illnesses, hospitalizations, operations, and drug used.
Fear
Older adult may be reluctant to report symptoms because they fear hospitalization which they may associated with dying.
Patients should be asked about educational level, job held, known exposures to radioactivity and current and past hobbies.
Economic difficulties due to retirement, a fixed income, or death of a spouse or partner are discussed.
Financial or health problems may result in loss of a home , social status, or independence.