Collecting

Subjective Data:
The Health Interview

Marina Gharibian PhD RN

Clinical Associate Professor
NURS 202 Spring 22-23
 Is an integral part of nursing health assessment.
Subjective data consist of
 Sensations or symptoms
 Feelings
 Perceptions
Collecting  Desires
subjective data  Preferences
 Beliefs
 Ideas
 Values
 Personal information
The nursing interview
Obtaining a valid nursing health history
requires professional, interpersonal, and
interviewing skills. The nursing interview is a
communication process that has two focuses:
 Establishing rapport and a trusting
relationship with the client to elicit accurate
and meaningful information and
 Gathering information on the client’s
developmental, psychological, physiologic,
sociocultural, and spiritual statuses.
Interviewing:
Phases of the interview

preintroductory, introductory, working, and summary/closing

phases.
  The health interview is a way of
soliciting information from the client.
This interview may also be called a
nursing history.
Admission interview: If the interview is
The Health

conducted when a client is admitted to a
healthcare facility.
Interview  Medical history: When a physician
obtains this information.
The RN assesses the data and works with
the team to formulate a nursing diagnosis
and plan of care.
Introductory Phase

introduces himself to explains the purpose of

the client, the interview,

assures the client that

discusses the types of
confidential
questions that will be
information will remain
asked,
confidential,

develops trust and rapport

makes sure that the client at this point in the
is comfortable (physically
and emotionally) and has interview by conveying a
privacy. sense of priority and
interest in the client.
 elicits the client’s comments about major
biographic data, reasons for seeking care, history of
present health concern, past health history, family
history, review of body systems for current health
problems, lifestyle and health practices, and
developmental level.

Working listens, observes cues, and uses critical

thinking skills to interpret and validate
Phase information received from the client.

The nurse and client collaborate to

identify the client’s problems and
goals.
Summary and Closing Phase

summarizes information
validates problems and goals
obtained during the working
with the client
phase and

identifies and discusses

possible plans to resolve the makes sure to ask if anything
problem (nursing diagnoses else concerns the client and if
and collaborative problems) there are any further questions
with the client.
Communication During the Interview
Verbal-nonverbal

Nonverbal Communication: is as
important as verbal communication.
• appearance,
• demeanor (Greet the client calmly and focus your
full attention on her. Do not enter the room laughing
loudly, yelling to a coworker),
• facial expressions (keep your expression neutral and
friendly. If your face shows anger or anxiety, the
client will sense it and may think it is directed
toward him or her),
• attitude (One of the most important nonverbal skills
to develop as a health care professional is a
nonjudgmental attitude. Being nonjudgmental
involves not “preaching” to the client or imposing
your own sense of ethics or morality on him.
Verbal Communication

Laundry list: “Is the pain

:Open-ended questions
Closed ended questions: severe, dull, sharp, mild,
typically begin with the words
“when” or “did” ex. “When cutting, or piercing?” “Does
“how” or “what.” ex. “How
did your headache start?” the pain occur once every year,
have you been feeling lately?”
day, month, or hour?”

Rephrasing: For example, your client, Inferring: Your client, Mrs. J., tells you that Providing information:
Mr. G., tells you that he has been really she has bad pain. You ask where the pain is,
tired and nauseated for 2 months and and she says, “My stomach.” You notice the Make sure you answer every
that he is scared because he fears that he client has a hand on the right side of her lower
abdomen and seems to favor her entire right
question as well as you can.
has some horrible disease. You might side. You say, “It seems you have more If you do not know the
rephrase the information by saying,
“you are thinking that you have a
difficulty with the right side of your stomach”
(use the word “stomach” because that is the
answer, explain that you will
serious illness?” term the client used to describe the abdomen). find out for the client.
Gerontologic Variations in Communication
 assess hearing acuity.
 speak slowly, always face the client during
the interview
 Speak clearly and use straightforward
language during the interview with the
elderly client. Ask questions in simple
terms.
 Being older physically does not mean the
client is slower mentally. Showing respect
is very important. However, if the older
client is mentally confused or forgetful, it
is important to have a significant other
(e.g., spouse, child, close friend) present.
Interacting with clients with various emotional
states

Anxious Client Angry Client

• Provide the client with simple, organized • Approach this client in a calm, reassuring, in-
information in a structured format. control manner.
• Explain who you are and your role and • Allow him to ventilate feelings.
purpose. • However, if the client is out of control, do not
• Ask simple, concise questions. argue with or touch the client.
• Avoid becoming anxious like the client. • Obtain help from other health care
• Do not hurry and decrease any external professionals as needed.
stimuli.
 Interacting with clients with various emotional
states
When Discussing Sensitive Issues (for
Depressed Client Seductive Client example, Sexuality, Dying,
Spirituality)
• Express interest in and • Set firm limits on overt sexual • be aware of your own thoughts and
understanding of the client and client behavior and avoid feelings regarding dying, spirituality,
and sexuality;
respond in a neutral manner. responding to subtle seductive • then recognize that these factors may
• Do not try to communicate in behaviors. affect the client’s health and may need
an upbeat, encouraging • Encourage client to use more to be discussed with someone.
manner. This will not help the appropriate methods of coping • Ask simple questions in a
depressed client in relating to others. nonjudgmental manner.
• Allow time for ventilation of client’s
feelings as needed.
• If you do not feel comfortable or
competent discussing personal,
sensitive topics, you may make
referrals as appropriate, for example,
to a pastoral counselor for spiritual
concerns or other specialists as
needed.
History of Present Health Concern
Examples of what the nurse would ask a client with back pain.
• “When did you first notice the pain in your back?
• How long have you experienced it? Has it become worse, better, or stayed
the same since it first occurred?”
• What does the pain feel like? Where does it hurt the most?
• Does it radiate or go to any other part of your body?
• How intense is the pain?
• Do you have any other problems that seem related to this back pain?”
• “What do you think caused this problem to start?”
• “What makes your back hurt more? What makes it feel better?
• Have you tried any treatments to relieve the pain such as aspirin or
acetaminophen (Tylenol) or anything else?”
• “How does the pain affect your life and daily activities?”
 “What diseases did you have as a child such as measles or mumps?

What immunizations did you get and are you up to date now?”

“Do you have any chronic illnesses? If so, when was it diagnosed?
How is it treated?

Past Health “What illnesses or allergies have you had? How were the illnesses
treated?”
History “Have you ever been pregnant and delivered a baby? How many
times have you been pregnant/ delivered?”

“Have you ever been hospitalized or had surgery? If so, when? What
were you hospitalized for or what type of surgery did you have?

“Have you experienced any accidents or injuries? Please describe

them.”
Family Health History

As researchers discover more and more health problems

that seem to run in families and that are genetically based,
the family health history assumes greater importance.

The family history should include as many genetic

relatives as the client can recall.
• maternal and paternal grandparents,
• aunts and uncles on both sides, parents,
• siblings, and the client’s children.
• Include the client’s spouse but indicate that there is no genetic link.
  Description of Typical Day “What is your daily pattern of
activity?”
 Nutrition and Weight Management
 Sleep and rest

Lifestyle and  Activity Level and Exercise

 Medication and Substance Use
Health  Self-Concept and Self-Care Responsibilities “How often do
Practices you have medical checkups or screenings?” “How often do
you see the dentist or have your eyes examined?”
Profile  Values and Belief System “Is a relationship with God (or
another higher power) an important part of your life?”
 Education and Work
 Stress Levels and Coping Styles “How do you manage anger or
stress?” “Where do you usually turn for help in a time of
crisis?”