COLLECTING

SUBJECTIVE DATA
Prof. Vinz Acena, MAN, RN, RM
OBJECTIVES

Discuss the purpose for Explain types of

01 each of the four phases of 02 communication to avoid
a client interview in the client interview

Describe effective verbal & Explain how a nurse

03 nonverbal communication 04 would use the “COLDSPA”
techniques to collect subjective mnemonic to analyze a
client data. client symptom
 01
Collecting
Subjective Date
COLLECTING SUBJECTIVE DATA is an integral part of
interviewing the client to obtain a nursing health history.
Consist of:
1. Sensations or symptoms
2. Feeling, Perceptions
3. Desires, Preferences
4. Beliefs, Ideas
5. Values
6. Personal Information
SUBJECTIVE DATA
• can be elicited and verified only by the client.
• Provide clues to possible physiological,
psychological, and sociologic problems

*The information is obtained through

interviewing.
** Therefore, effective interviewing skills are
vital for accurate and thorough collection of
subjective data.
INTERVIEWING
Obtaining a valid nursing health history
requires professional, interpersonal, and
interviewing skills.

The nursing interview is a communication process

that has two focuses.
1. Establishing rapport and trusting relationship
with the client to elicit accurate and meaningful
information.
The nursing interview is a communication process
that has two focuses (cont.)

2. Gathering information on the client’s

development, psychological, physiological,
sociocultural, and spiritual status to identify
deviations that can be treated with nursing and
collaborative interventions or strengths that can be
enhanced through nurse-client collaboration.
4 BASIC PHASES OF INTERVIEW
1. PREINTRODUCTORY PHASE
• The nurse reviews the medical record
before meeting with the client.
• Knowing some of the client’s already
documented biographical information may
assist the nurse with conducting the
interview.
• If the client has been in the system for some
time, the record may reveal additional
information.
2. INTRODUCTORY PHASE
• After introducing yourself to the client,
the nurse explains the purpose of the
interview, discusses the types of
questions that will be asked, explains the
reason for taking notes, and assures the
client that confidential information will
remain confidential.
3. WORKING PHASE
• During this phase, the nurse elicits the client’s
comments about major biographical data,
reasons for seeking care, history of present
health concern, past health history, family
history, review of body systems (ROS) for
current health problems, lifestyle and health
practices, and development
3. WORKING PHASE (cont.)
• The nurse the listens, observes cues, and uses critical
thinking skills to interpret and validate information
received from the client.
• The nurse and client collaborate to identify the client’s
problems and goals.
4. SUMMARY PHASE & CLOSING PHASE
• The nurse summarizes information obtained
during the working phase and validates
problems and goals with the client
• Identifies and discusses possible plans to
resolve the problem with the client
• Finally, the nurse makes sure to ask if anything
else concerns the client and if there are any
further questions.
 02
Communication
During the Interview
NONVERBAL COMMUNICATION
• Nonverbal communication is as important as verbal
communication.
1. Appearance
2. Demeanor
3. Facial Expression
4. Attitude
5. Silence
6. Listening
1. Appearance
• First take care to ensure that
your appearance is
professional.

*The client is expecting to see

health professional; therefore,
you should look the part.
2. Demeanor
• Your demeanor should also be professional. When you
enter a room to interview a client, display poise.
• Focus on the client and the upcoming interview and
assessment.
• Greet the client calmly, by name and not references
such as honey, sweetie or sugar
• Do not be overwhelmingly friendly or ‘touchy’, many
clients are uncomfortable with this type of behavior.
• It is best to maintain a professional distance.
3. Facial Expression
• No matter what you think about a
client or what kind of day you are
having , keep your expression neutral
and friendly.
• Displaying a neutral expression does
not mean that your face lacks
expression. It means using the right
expression at the right time.
3. Facial Expression (cont.)

*If your face shows anger or anxiety, the client will sense
it and may think it is directed toward him or her.
**If you cannot effectively hide your emotions, you may
want to explain briefly that you are angry or upset about
a personal situation
4. Attitude

• One of the most important nonverbal skills to develop

as a health care professional is a nonjudgmental
attitude. All clients should be accepted, regardless of
beliefs, ethnicity, lifestyle and health care practices.
• Do not act as though you feel superior to the client or
appear shocked, disgusted, or surprised at what you
are told.
4. Attitude (cont.)

• Do not act as though you feel superior to the client or

appear shocked, disgusted, or surprised at what you
are told.

*these attitudes will cause the client to feel

uncomfortable about opening up to you, and important
data concerning their health status could be withheld.
5. Silence

• Periods of silence allow you

and the client to reflect and
organize thoughts, which
facilitate more accurate
reporting and data collection
6. Listening

• To listen effectively, you need to maintain

good eye contact, smile or display an open,
appropriate facial expression, and maintain an
open body position (open arms and hands,
and lean forward).
• Keep an open mind
• Avoid engaging with an electronic device
instead of the client
 Nonverbal Communication to
Avoid!

1. Excessive or insufficient Eye Contact

2. Distraction And Distance
3. Standing
4. Biased or Leading Questions
5. Rushing Through The Interview
6. Reading the Questions
VERBAL COMMUNICATION
1. Open-Ended Questions
2. Closed-Ended Questions
3. Laundry List
4. Rephrasing
5. Well-Placed Phrases
6. Inferring
7. Providing Information
1. Open-Ended Questions
• Used to elicit the client’s feelings and perceptions
• They typically begin with the words “How” or “what”
• These types of questions are important because they
require more than a one-word response from the
client and, therefore, encourage description
• May help to reveal significant data about the client’s
health status.
2. Closed-Ended Questions
• To obtain facts and to focus on specific information.
• The client can respond with one or two words.
• Typically begin with the words “when” or “did”
• Useful in keeping the interview on course
• Used to clarify or obtain more accurate information
about issues disclosed in response to open-ended
question.

e.g. When did your headache start?

3. Laundry List
• Another way to ask questions is to provide the client
with a list of words to choose from in describing
symptoms, conditions, or feelings.
4. Rephrasing
• Rephrasing information the client has provided is an
effective way to communicate during the interview
• This technique helps you clarify information the client
has stated; it also enables you and the client to reflect
on what was said.
5. Well-placed Phrases
• The nurse can encourage client verbalization by using
well-placed phrases.
• Listen closely to the client during their description and
phrases such as “uh-huh”, ”yes”, or “I agree” to
encourage the client to continue.
6. Inferring
• Inferring information from what the client tells you
and what you observe in the client’s behavior may
elicit more data or verify existing data.
7. Providing Information
• Another important thing to do throughout the interview is
to provide the client with information as questions and
concerns arise.
• Make sure to answer every question thoroughly as you can.
• The more clients know about their own health, the more
likely they are to become equal participants in caring for
their health.
*If you do not know the answer, explain that you will find out.
Special 03
Considerations
During the Interview
1. Gerontologic Variations in
Communication
• Age affects and commonly slows all body
systems to varying degrees.
• However , normal aspects of aging do not
necessarily equate with a health problem,
so it is important not to approach an
interview with an elderly client assuming
that there is a health problem.
1. Gerontologic Variations in Communication (cont.)
• You must first assess hearing acuity
*hearing loss occurs normally with age, and undetected hearing
loss is often misinterpreted as mental slowness or confusion.
** If you detect hearing loss, speak slowly, face the client at all
times during during the interview.
***Position yourself so that you are speaking on the side of the
client that has the ear with better acuity.
****Do not yell at the client
2. Cultural Variations in
Communication
• Be aware of possible variations in
your communication style and the
client’s.
• Variation in willingness to openly
express emotional distress or pain
• Variation in ability to receive
information
3. Emotional Variations in Communication
• Not every client you encounter will be
calm, friendly, and eager to participate
in the interview process.
• Clients’ emotions vary for a number of
reasons. They may be scared or anxious
about their health or about disclosing
personal information, angry that they
are sick or about having to have an
examination, depressed about their
health or other life events
 INTERACTING WITH CLIENTS WITH
VARIOUS EMOTIONAL STATES

1. When interacting with an anxious client

2. When interacting with an angry client
3. When interacting with a depressed client
4. When interacting with a manipulative client
5. When interacting with a seductive client
6. When discussing sensitive issues (e.g., sexuality,
dying, spirituality)
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 ANGRY CLIENT

• Approach this client in a calm, reassuring, in-control

manner.
• Allow them 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
WHEN INTERACTING WITH 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 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.
• If the overt sexuality continues, do not interact
without a witness.
• Report inappropriate behavior to a supervisor
 WHEN DISCUSSING SENSITIVE ISSUES
• 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.
• 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.
COMPLETE HEALTH
HISTORY
The health history is an excellent way
to begin the assessment process
because it provides the foundation
for clinical judgments in identifying
nursing problems, where to focus,
and areas where a more detailed
physical examination may be needed.
8 SECTIONS
OF HEALTH HISTORY
1. Biographical Data
2. Reasons for seeking health care
3. History of present health concern
4. Personal Health History
5. Family Health History
6. ROS for current health problems
7. Lifestyle and health practices
profile
8. Developmental Level
SYMPTOM ANALYSIS

Components of the COLDSPA Symptom Analysis Mnemonic

C Character - Describe the sign or symptom

(feeling, appearance, sound,
smell, or taste)

O Onset - When did it begin?

L Location - Where is it? Does it radiate?

Does it occur anywhere else?
SYMPTOM ANALYSIS

D Duration - How long does it last?

Does it recur? Does it come and go
or is it constant?

S Severity - How bad is it?

Rate it on a scale of 1-10
SYMPTOM ANALYSIS

P Pattern - What makes it better or worse?

Does it occur anywhere else?

A Associated Factors - What other symptoms

occur with it?
SYMPTOM ANALYSIS

PQRST Pain Analysis Mnemonic

P Provocative/ palliative
(What provokes or relieves the pain?)
Q Quality
(Describe the character of the pain [sharp,
stabbing, aching]
R Radiates
(Is the pain localized or does it spread to other
areas?)
SYMPTOM ANALYSIS

PQRST Pain Analysis Mnemonic (cont.)

S Severity
(How bad is the pain? Does it interfere with your
ADLs or sleep? Rate it on a scale of 1-10 with 10
being the worst.)
T Timing
(When does the pain occur, and how long does it
last? How long before it recurs?)
 SUMMARY
Collecting subjective data is a key
step of nursing health assessment.
Subjective data consist of
information elicited and verified
only by the client. Interviewing is
the means by which subjective
data are gathered.
 THANK YOU!
Prof. Francis Vincent L. Acena, MAN, RN, RM