Taking a history
If you notice a change or deterioration in your patient/client's health, talk with them to check if the symptoms they have are new or getting worse. If you haven’t been trained in conducting and interpreting a subjective assessment and basic physical assessment (such as vital signs etc) you should refer to somebody who can investigate the concerns you have raised through your conversation with the patient/client.
Consider referral to a nurse or GP.
When doctors or nurse specialists assess a patient, learning about how the symptoms developed and what was also happening around that time that is relevant to the symptoms of the main problem is always the most important part. This is called 'taking a history'.
By using a mixture of open and closed questions you can get as much information as possible. You may need to inform your line manager, medical or nursing staff if the person gives their consent.
Encourage your patient/client to:
- Describe the symptoms.
- Give an indication of the timescale of when the symptoms developed.
- Describe how it affects their daily life and activities.
The patient’s smoking history, certain childhood illnesses and in some cases their work history can be important factors in the diagnosis of respiratory disease.
Be aware that other non-respiratory conditions can also cause symptoms such as breathlessness and cough.
