lOMoAR cPSD| 16912828

Chapter 2 Collecting Subjective Data The Interview and

Health History
 lOMoAR cPSD| 16912828

Chapter 2 Collecting Subjective Data: TheInterview and Health History

Learning Objectives
1. Discuss the purpose for each of the four phases of a client interview.
a. Pre-introductory- nurse reviews med. Record BEFORE meeting wclient. Knowing some info may help
w interview.
i. If client has been in sys. This may reveal helpful info, such as:difficulty hearing in one ear/ past
health history.
ii. If there is no medical record, the nurse will need to RELY onthe interviewing skills, to obtain valid
& reliable data from client.
b. Introductory- nurse explains purpose of interview, types of questions to be asked, reason for note taking, &
assures client that confidential infowill remain confidential.
i. Nurse must: make sure client is COMFORTABLE (physically& emotionally) & privacy
ii. Interview: conducted @ eye level (shows respect & equality)
1. Nurse: develop trust & rapport (IMPORTANT); conveya sense of priority & interest in clients
a. Developing rapport depends on verbal & nonverbal communications from the
NURSE
ii. We are trying to establish a relationship:
1. If unsuccessful our data might not be accurate
c. Working (lengthy part)- the nurse receives info from the patient, such as:major biographical data, reasons
for seeking care, history of present health concern, past health history, fam. History, review of B.S. (ROS) ,
lifestyle, & developmental level.
i. Nurse: listens, observes cues, & uses critical thinking skills tointerpret & validate info.
ii. Nurse & client: work together to identify client's problems &goals
iii. Ask variety of questions, get to know patient
d. Summary/closing-
e. Nurse: summarizes info obtained & validates problems/goals w/client.
i. Identifies & discusses POSSIBLE plans to resolve theproblem w/ client
ii. Asks if anything else concerns the client/ has any questions.
2. Describe effective verbal and nonverbal communication techniques to collectsubjective client data.
a. Nonverbal
i. Appearance- professional. (ex: comfy & neat clothes; lab coat/uniform); name tag & credential
must be visible; neathairstyle; minimal jewelry; short fingernails
ii. Demeanor- professional.
1. Focus on client & interview/assessment. Don’t enterloudly
2. Greet client calm & by name.
3. Full attention on client
4. professional distance :Avoid overwhelminglyfriendliness
 lOMoAR cPSD| 16912828

iii. Facial expression- shows what you truly think

1. Keep it neutral
2. If feeling upset, then briefly explain to avoid making theclient feel it is directed at them &
helps build a trusting relationship.
3. USE RIGHT EXPRESSIONS AT THE RIGHT TIME
iv. Attitude- NONJUDGMENTAL ATTITUDE
1. ALL clients should be ACCEPTED (beliefs, ethnicity,lifestyle)
2. Don’t' act like you're superior/ disgusted.
1. Especially when they’re telling you something bc it may cause the pt to feel
uncomfortable &may withhold info
3. Make the client feel comfortable
4. Do not impose YOUR OWN sense of belief/ lecture theclient
5. Accept the client, be understanding of the habit, andwork together to improve the client’s
health
v. Silence- periods of silence allow you & client to reflect &organize thoughts = accurate
reporting & data collection
vi. Listening- MOST IMPORTANT SKILL TO LEARN &DEVELOP
1. Effective listening- maintain good eye contact, smile/ appropriate facial expression, open
body positions
2. Avoid bias
3. KEEP AN OPEN MIND
4. Avoid: crossing arms, sitting back, thinking about otherthings, looking @ phone
5. Takes concentration & practice
vii. Avoid:
1. Excessive/ insufficient eye contact
2. Distracton: may tell pt you don’t care
3. Distance: not too close/ far
a. Verbal
i. Open-ended questions- used to elicit client's feelings &perceptions
1. Begin w/ how/what (ex: how have you been feeling lately?)
2. Requires the pt to give you > 1 word response fromclient & encourage description
3. May help w/ revealing significant data about health status
4. Ex: Imagine yourself interviewing an elderly male client who is at the primary care provider’s
office because of diabetic complications. He mentions casually to you, “Today is the 2-month
anniversary of my wife’s death fromcancer.” Failure to follow up with an open-ended question
such as “How does this make you feel?” may result in theloss of important data that could
provide clues to the client’s current state of health
ii. Close-ended questions- Use to obtain facts & focus on specificinfo
1. Begin w/ when/did (ex: when did your headache start)
2. Keeps interview on course & clarify/ obtain moreaccurate info
3. For example, in response to the open-ended question"How have you been feeling lately?"
the client says,
 lOMoAR cPSD| 16912828

"Well, I've been feeling really sick to my stomach and I don't feel like eating because of it." You
may be able tofollow up and learn more about the client's symptom with a closed- ended
question such as "When did the nausea start?"
4. Do you smoke?
5. Did you get a physical/flu- shot?
ii. Laundry list- provide client w/ a list of words to choose fromwhen describing symptoms,
conditions, or feelings
1. Helps obtain specific answers & reduces likelihoodof client perceiving/ providing an
unexpected answer
2. For example, "Is the pain severe, dull, sharp, mild, cutting, or piercing?" "Does the pain
occur once everyyear, day, month, or hour?
ii. Rephrasing- effective way to communicate
1. Helps you to clarify info the client has stated & helps you & client reflect on what
the client said
2. For example, your client, Mr. G., tells you that he has been really tired & nauseated for 2
months & that he isscared because he fears that he has some horrible disease. You might
rephrase the information by saying,"You are thinking that you have a serious illness?"
ii. Well-placed phrases- encourage client verbalization byusing well-placed phrases
1. For example, if the client is in the middle of explaining asymptom & believes that you are not
paying attention, you may fail to get all necessary information. Listen closely to the client
during his/her description & use phrases such as uh-huh/yes/ I agree, to encourage the
client.
2. “Tell me more, keep going, I see”
ii. Inferring- inferring info from the what the client tells you & what you observe from their behavior
may elicit more data/verify existing data.
1. Do not lead client to answers that are not true
2. If used properly, it helps elicit the most accurate datapossible
3. Ex: your client, Mrs. J., tells you that she ahs bad pain.You ask where the pain is, and she
says, "My stomach." You notice the client has a hand on the rightside of her lower abdomen
& seems to favor her entireright side. You say, "It seems you have more difficulty with the
right side of your stomach"
ii. Providing info- provide info as questions & concerns arise
1. Answer every question as thoroughly as possible.
2. If you don’t know the answer, explain that you will findout.
ii. Summarize- recap what you talked about
iii. Avoid:
1. biase/ leading q’s
2. rushing through interview
3. reading q’s
3. Explain types of communication to avoid in the client interview.
a. Nonverbal-
 lOMoAR cPSD| 16912828

i. Excessive/ insufficient eye contact- may make client feeluncomfortable

1. By not looking at the eye, it may make the client feel like youare hiding something
2. Ex: establish eye contact when the client is speaking to youbut look down at your notes from time
to time.
ii. Distraction & distance- avoid being occupied w/ something else.
1. May make the client believe that the interview may beunimportant to you.
2. Avoid the distant feeling
a. Client will sense it & less likely to answer the questionsthoroughly
3. Physical distance may portray a noncaring attitude/ desire toavoid close contact
i. Standing- Puts you & client @ different levels.
1. May be perceived at the superior & may make client feelinferior
2. Care should be an equal partnership (client= health careprovider)
3. May cause info to be held back
4. May be perceived as untrustworthy, judgmental, ordisinterested.
b. Verbal-
i. Biased/ leading questions- cause client to provide answers that maynot be true.
1. May lead client to think you want them to answer a certainway.
2. Ex: you ask, " You don’t feel bad, do you?" the client may think that you think that they shouldn't feel
bad & will say "no" even ifit's not true
ii. Rushing through interview- asking questions on top of questions
1. May cause client to answer incorrectly, because they didn'thear the question clearly.
2. Client may believe that the nurse has little concern for theirsituation
3. May cause important info to be left out.
ii. Reading questions- may cause distraction from client & cause animpersonal interview process.
1. Client may feel ill at ease opening up to formatted questions.
4. Describe ways to adapt the interview for the older client.
a. Age affects & slows all body systems.
b. It is important to approach an interview w/ an elderly client assumingthat there IS a health problem
c. Assess hearing acuitiy, hearing loss is normal. If hearing loss isdetected
i. Speak slowly,
ii. Face client at ALL times
iii. Position yourself to speak on the side of the client that has theear w/ > acuity.
iv. Older clients may feel VULNERABLE & SCARED
1. They may need to feel like they can trust you.
Establish & maintain trust, privacy, & partnership
2. They may feel like their health complaints are ignored/not take seriously, so they withhold
info.
3. Assure pt that info will only be discussed w/ those
 lOMoAR cPSD| 16912828

caring for them.

4. Show respect
5. Take into account what they say
v. Tips: speak clearly & straightforward language.
1. Ask questions in simple terms
2. Avoid medical jargon/ modern slang (DO NOT TALK
DOWN)
3. Show respect
5. Describe ways to adapt the interview for the client with emotional issues.
INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL
STATES
WHEN INTERACTING WITH AN ANXIOUS CLIENT
• Provide the client with simple, organized information in a structured
format.
• Explain who you are, along with your role and purpose.
• Ask simple, concise questions.
• Avoid becoming anxious like the client.
• Do not hurry, and decrease any external stimuli.
WHEN INTERACTING WITH AN ANGRY CLIENT
• Approach this client in a calm, reassuring, in-control manner.
• Allow him to ventilate feelings. However, if the client is out of control, do
not argue with or touch the client.
• Obtain help from other health care professionals as needed.
• Avoid arguing and facilitate personal space so that the client does not feel
threatened or cornered.
• Never allow the client to position him or herself between you and the door.
WHEN INTERACTING WITH A DEPRESSED CLIENT
• Express interest in and understanding of the client and respond in a
neutral manner.
• Do not try to communicate in an upbeat, encouraging manner. This will not
help the depressed client.
WHEN INTERACTING WITH A MANIPULATIVE CLIENT
• Provide structure and set limits.
• Differentiate between manipulation and a reasonable request.
• If you are not sure whether you are being manipulated, obtain an objective
opinion from other nursing colleagues.
WHEN INTERACTING WITH A SEDUCTIVE CLIENT
• Set firm limits on overt sexual client behavior and avoid responding to
subtle seductive behaviors.
• Encourage client to use more appropriate methods of coping in relating to
others.
• If the overt sexuality continues, do not interact without a witness.
• Report inappropriate behavior to a supervisor.
WHEN DISCUSSING SENSITIVE ISSUES (E.G., SEXUALITY, DYING,
SPIRITUALITY)
 lOMoAR cPSD| 16912828

• First, be aware of your own thoughts and feelings regarding dying,

spirituality, and sexuality; then recognize that these factors may affect the
client’s health and may need to be discussed with someone.
• Ask simple questions in a 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.

6. Discuss the ways that ethnicity can affect communication patterns.

a. If misunderstanding/miscommunication occurs seek help (aka: culture
broker)
i. May have to use an interpreter (consider who that interpreter
might be). Also, communication through pics. May help
b. Individuals may be reluctant to share personal info w/ "strangers"
c. Variation in meaning conveyed by language
i. Ex: a client who doesn't speak the predominant language may
not know what a certain med. term means & will not know how
to answer your question.
d. Variation in disease/illness perception:
i. Ex: in Latin America = susto is caused by shock/fright.
e. Variation in past, present, or future time oriented
f. Variation in willingness to openly express emotional distress/ pain.
7. Describe how to use a genogram to illustrate a client’s family health history.
a. A genogram helps organize & illustrate client’s family history
b. Provide a key for the symbols used
c. Identify relatives by: living/dead, age, & provide brief list of diseases/
condition
i. A/W – alive & well if relative has no problems
d. Males & females

e. Deceased relatives: X inside square/circle w/ age at death & COD

f. Straight vertical & horizontal lines to show relationships
g. Horizonal dotted line can indicate spouse
h. Vertical dotted line can indicate adoption

i.
 lOMoAR cPSD| 16912828

8. Identify the major categories of a complete client health history.

a. Biographical Data
i. Name
ii. Address
iii. Phone
iv. Gender
v. Provider of history (patient or other)
vi. Birth date
vii. Place of birth
viii. Race or ethnic background
ix. Primary and secondary languages (spoken and read)
x. Marital status
xi. Religious or spiritual practices
xii. Educational level
xiii. Occupation
xiv. Significant others or support persons (availability)
b. Reasons for Seeking Health Care
i. Reason for seeking health care (major health problem or
concern)
ii. Feelings about seeking health care (fears and past
experiences)
c. History of Present Health Concern Using COLDSPA
i. Character (How does it feel, look, smell, sound, etc.?)
ii. Onset (When did it begin; is it better, worse, or the same
since it began?)
iii. Location (Where is it? Does it radiate?)
iv. Duration (How long does it last? Does it recur?)
v. Severity (How bad is it on a scale of 1 [barely noticeable] to
10 [worst pain ever experienced]?)
vi. Pattern (What makes it better? What makes it worse?)
vii. Associated factors (What other symptoms do you have with
it? Will you be able to continue doing your work or other
activities [leisure or exercise]?)
d. Past Health History
i. Problems at birth
ii. Childhood illnesses
iii. Immunizations to date
iv. Adult illnesses (physical, emotional, mental)
v. Surgeries
vi. Accidents
vii. Prolonged pain or pain patterns
viii. Allergies
ix. Physical, emotional, social, or spiritual weaknesses
x. Physical, emotional, social, or spiritual strengths
e. Family Health History
i. Age of parents (Living? Date of death?)
ii. Parents’ illnesses and longevity
iii. Grandparents’ illnesses and longevity
iv. Aunts’ and uncles’ ages and illnesses and longevity
 lOMoAR cPSD| 16912828

v. Children’s ages and illnesses or handicaps and longevity

f. Review of Systems for Current Health Problems
i. Skin, hair, and nails: color, temperature, condition, rashes,
lesions, excessive sweating, hair loss, dandruff
ii. Head and neck: headache, stiffness, difficulty swallowing,
enlarged lymph nodes, sore throat
iii. Ears: pain, ringing, buzzing, drainage, difficulty hearing,
exposure to loud noises, dizziness, drainage
iv. Eyes: pain, infections, impaired vision, redness, tearing,
halos, blurring, black spots, flashes, double vision
v. Mouth, throat, nose, and sinuses: mouth pain, sore throat,
lesions, hoarseness, nasal obstruction, sneezing, coughing,
snoring, nosebleeds
vi. Thorax and lungs: pain, difficulty breathing, shortness of
breath with activities, orthopnea, cough, sputum, hemoptysis,
respiratory infections
vii. Breasts and regional lymphatics: pain, lumps, discharge
from nipples, dimpling or changes in breast size, swollen and
tender lymph nodes in axilla
viii. Heart and neck vessels: chest pain or pressure,
palpitations, edema, last blood pressure, last ECG
ix. Peripheral vascular: leg or feet pain, swelling of feet or legs,
sores on feet or legs, color of feet and legs
x. Abdomen: pain, indigestion, difficulty swallowing, nausea
and vomiting. Gas, jaundice, hernias
xi. Male genitalia: painful urination, frequency or difficulty
starting or maintaining urinary system, blood in urine, sexual
problems, penile lesions, penile pain, scrotal swelling,
difficulty with erection or ejaculation, exposure to STIs
xii. Female genitalia: pelvic pain, voiding pain, sexual pain,
voiding problems (dribbling, incontinence), age of menarche
or menopause (date of last menstrual period), pregnancies
and types of problems, abortions, STIs, HRT, birth control
methods
xiii. Anus, rectum, and prostate: pain, with defecation,
hemorrhoids, bowel habits, constipation, diarrhea, blood in
stool
xiv. Musculoskeletal: pain, swelling, redness, stiff joints,
strength of extremities, abilities to care for self and work
xv. Neurologic: mood, behavior, depression, anger, headaches,
concussions, loss of strength or sensation, coordination,
difficulty with speech, memory problems, strange thoughts or
actions, difficulty reading or learning
g. Lifestyle and Health Practices
i. Description of a typical day (AM to PM)
ii. Nutrition and weight management
iii. 24-hour dietary intake (foods and fluids)
iv. Who purchases and prepares meals
v. Activities on a typical day
 lOMoAR cPSD| 16912828

vi. Exercise habits and patterns

vii. Sleep and rest habits and patterns
viii. Use of medications and other substances (caffeine, nicotine,
alcohol, recreational drugs)
ix. Self-concept
x. Self-care responsibilities
xi. Social activities for fun and relaxation
xii. Social activities contributing to society
xiii. Relationships with family, significant others, and pets
xiv. Values, religious affiliation, spirituality
xv. Past, current, and future plans for education
xvi. Type of work, level of job satisfaction, work stressors
xvii. Finances
xviii. Stressors in life, coping strategies used
xix. Residency, type of environment, neighborhood,
environmental risks
h. Developmental Level
i. Erikson’s
9. Explain how a nurse would use the “COLDSPA” mnemonic to analyze a client
symptom.
Mneumonic Question

Character Describe the sign or symptom (feeling, appearance, sound, smell, or taste
if applicable).
“What does the pain feel like?”

Onset When did it begin?

“When did this pain start?”

Location Where is it? Does it radiate? Does it occur anywhere else?

“Where does it hurt the most? Does it radiate or go to any other part of
your body?”

Duration How long does it last? Does it recur?

“How long does the pain last? Does it come and go or is it constant?”

Severity How bad is it? How much does it bother you?

“How intense is the pain? Rate it on a scale of 1–10.”

Pattern What makes it better or worse?

“What makes your back pain worse or better? Are there any treatments
you’ve tried that relieve the pain?”

Associated factors/How it What other symptoms occur with it? How does it affect you?
affects the client “What do you think caused it to start?
Do you have any other problems that seem related to your back pain?
How does this pain affect your life and daily activities?”
lOMoAR cPSD| 16912828