Description
History collection for substance-dependent patients is a crucial step in understanding their addiction patterns, identifying underlying causes, and planning effective treatment. It involves gathering detailed information about the patient’s substance use history, medical background, psychological state, and social influences
Aims of History Taking
- To treat any emergency health problems.
- To identify/confirm the substance patient is using.
- To determine the degree of dependence.
- To identify physical and mental health problems.
- To identify social problems, housing, employment, domestic violence, etc.
- To identify any risk behavior.
- To determine the patient’s expectations of treatment and desire to change.
- To determine the need to substitute medications.
- To determine any risk to dependent family.
Substances Generally Used
- Mood altering substances such as Marijuana (Hashish), cocaine, Heroin and Methamphetamine.
- Prescription of over-the-counter drugs for purposes other than for which they are meant to be used or used in larger amounts.
- Alcohol and tobacco used for pleasure, improved performance and vigilance.
- Anabolic steroids used for body building.
- Club drugs such as:
- PCL-Phencyclidine
- LSD-Lysergic acid diethylamide
- MDMA-Methylenedioxy-methamphetamine.
Purpose of History Collection from Substance Abusers
The purpose of history Collection from substance abusers is to gather comprehensive information about their substance use patterns, medical and psychological health, and social influences to guide effective treatment. Here are the key objectives:
- Determine the type, frequency, and duration of substance use.
- Assess triggers, cravings, and withdrawal symptoms.
- Identify medical complications related to substance use, such as liver disease or cardiovascular issues.
- Assess for coexisting mental health disorders, including depression or anxiety.
- Explore family history of substance abuse and genetic predispositions.
- Assess social influences, including peer pressure and living conditions.
- Identify the patient’s readiness for change and motivation for recovery.
- Develop a personalized treatment plan, including detoxification, therapy, and rehabilitation.
- Establish support systems for sustained recovery.
- Recognize past relapse patterns and risk factors.
Principles of History Collection
- History taking requires linguistically and culturally effective communication skills.
- Interviewing skills and observation skills are essential.
- Comprehensive assessment of the patient including relevant body systems are to be included.
- Questions asked to patient must be in a non-threatening manner to help reduce anxiety.
- Information shared must serve for rapport-building and initiating nurse-patient relationship.
- Sufficient time must be allowed for patient to give proper information i.e., patient listening and repeated interviews may be needed to get adequate information.
Importance of Informants in History Collection
Information from patient’s relative/informant may be obtained for getting complete history and for authenticating the patient’s version of the disease process or development of the substance dependence.
Detailed information about the informant must also be considered such as:
- Name of the person.
- Relationship with the patient.
- Duration of relationship if not family.
- Intimacy level with the patient.
- Reliability of the informant.
Components of History
History of present illness:
- Age when drug/alcohol use started.
- Precipitating factors such as peer pressure, failure in examination, loss of job, loss of a dear one, loss of property, finance, etc.
- Name of the substance used.
- First pleasurable effect experienced.
- Nature of substance use: Occasional/regular/associated with symptoms or stress.
- Experience of well-being: Improving/deteriorating/unclear.
- Associated problems experienced: Anxiety, depression, suicidal tendency etc.
- Activities of daily living: Better/worse/no change.
- Functioning pattern: Social functioning, use of leisure time.
- Biological functioning: Appetite, sleep, bowel and bladder, sexual functioning.
- Mental functioning: Concentration, recall, mood pattern, attitude, interest etc.
- Interpersonal relationship: With family members, co-workers, and friends.
- Appearance of withdrawal symptoms at any attempt of stopping the conversation.
- Any attempt of detoxification of treatment.
- Any history of relapse.
Past medical and surgical history:
- Past hospitalization and treatment.
- Medications for any chronic illness.
- Any surgical treatment in the past.
- Any road accident while under the influence of substance.
- Any legal issues in the past.
Past psychiatric history:
- Any psychiatric illness and treatment taken.
- Past hospitalization for treatment of psychiatric problem.
- Any past treatment using electro convulsive therapy.
- Effect/improvement with treatment.
Substance (Drug/alcohol) related problems:
- Physical health: Weakness, fatigue, tachycardia, tachypnoea, dyspnoea, headache, hangover and blackouts.
- Psychological problems: Confusion, irritability, lack of concentration, poor insight, illusion and disorientation.
- Occupation: Regularity at workplace, relationship with colleagues and seniors, multiple change of job areas and place, effect on job productivity.
- Finance and economics effects: Spending salary on procuring drugs, frequent borrowing of money from others, thefts, robbery, selling valuables.
- Family and social relationships: Relationship with parents, spouse, children, friends, neighbours, relatives.
- Legal or crime history: Any theft, robbery, rape, murder etc.
Family history:
- Anyone in the family has similar psychiatric disorder.
- Do family members have any substance abuse disorder: Father, mother, siblings?
- Home situation and interpersonal relationship.
- Family history of mental illness, mental retardation or epilepsy.
- Use of addictive substance in the family by other family members.
Personal history:
- Significant events in patient’s life.
- Prenatal factors such as maternal illnesses.
- Significant events in childhood life such as parental separation, abuse, education, peer relationships, behavioural aspects, any complications.
- Adulthood relationship and occupational history.
- Major stresses and transitions such as marriage, parenthood, retirement or death of a partner and financial success or failure and how the patient has dealt with them.
- Sexual adjustment and problems, behavioural traits and social skills.
- Birth: Early development (childhood), education, occupation. Sexual-marital history, religious history, living situation.
Premorbid personality:
Premorbid personality refers to the patient’s personality traits prior to the disease process. It includes the following:
- Attitude towards self and others.
- Thinking pattern.
- Behavioral pattern.
- Strengths/abilities.
- Limitations/weaknesses/shortcomings.
- Hopes/ambitions.
- Type of personality.
- Family and social relationships.
- Use of leisure time.
- Reactions toward stressful events.
- Mood pattern: Pessimistic/optimistic, sadistic/ stable/ fluctuating/ cheerful/ dull/ moody/ self-control ability/ dependency.
- Self-appraisal of abilities/achievements/failures.
- Attitude towards work and feeling of responsibility.
- Moral attitude/religious beliefs.
- Living patterns: Reality/fantasy.
- Habits related to eating, sleeping, elimination.
- Any history of addiction.
- Relationship: likes to live alone/with group, makes friends easily/frequency of changing relationships.
- Relationship with opposite sex.
- Toleration related to criticisms.
Conducting a Sort History Collection Session
Conducting a history collection session for a substance abuse patient requires a structured, empathetic, and nonjudgmental approach to gather accurate information. Here’s how to proceed:
1. Establishing Rapport
- Begin with a warm, nonjudgmental introduction to make the patient feel comfortable.
- Explain the purpose of the session and assure confidentiality.
- Use open-ended questions to encourage honest responses.
2. Structured History Collection
A. Identification and Demographics
- “Can you tell me your full name, age, and occupation?”
- “Who do you live with, and what is your current living situation?”
B. Substance Use History
- “What substances have you used, and when did you start?”
- “How often and in what quantity do you use these substances?”
- “Have you ever tried to quit? If so, what happened?”
C. Medical and Psychiatric History
- “Have you been diagnosed with any medical or mental health conditions?”
- “Have you experienced withdrawal symptoms or overdoses?”
- “Are you currently taking any medications?”
D. Family and Social History
- “Is there a history of substance abuse in your family?”
- “How do your relationships with family and friends affect your substance use?”
- “Do you have a support system?”
E. Risk Assessment
- “Have you ever had thoughts of harming yourself or others?”
- “Do you feel safe in your current environment?”
- “Have you been involved in any legal issues related to substance use?”
3. Documentation and Follow-Up
- Record responses accurately and objectively.
- Identify patterns or concerns that require further evaluation.
- Plan next steps, including referrals or interventions.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- R.Sreevani, A Guide to Mental Health & Psychiatric Nursing, 6th Edition, 2024, Jaypee Publishers, ISBN 978-9366161686
- Sheila L. Videbeck, Psychiatric Nursing, Seventh Edition , 2017, Wolters Kluwer Publications, ISBN: 978- 1496355911
Stories are the threads that bind us; through them, we understand each other, grow, and heal.
JOHN NOORD
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