COLLECTING DIANA ROSE D.
SUBJECTIVE DATA EMERENCIANA, RN, MAN
SUBJECTIVE DATA CONSIST
OF:
Sensations of Preferences
symptoms Beliefs
Feelings Ideas
Perceptions Values
Desires Personal
information
TWO FOCUSES OF
INTERVIEW
1. Establishing 2. Gathering information on
rapport and a trusting the client’s developmental,
psychological, physiologic,
relationship with the sociocultural, and spiritual
client to elicit status to identify
accurate and deviations that can be
meaningful treated with nursing and
collaborative interventions
information or strengths that can be
enhanced through nurse –
client collaboration
TWO FOCUSES OF
INTERVIEW
PHASES OF INTERVIEW
PREINTRODUCTORY PHASE
INTRODUCTORY PHASE
WORKING PHASE
SUMMARY AND CLOSING
PHASE
PHASES OF THE INTERVIEW
PREINTRODUCTORY
INTRODUCTORY PHASE
PHASE
Review medical Introduce self
records Purpose
Type of question
Reason for taking notes
Confidentiality of info
Develop trust & rapport
PHASES OF THE INTERVIEW
WORKING PHASE SUMMARY & CLOSING
Biographical data PHASE
Reasons for seeking care Summarize information
History of present health taken during the
concern working phase
Past health history
Family health history Validates problems &
Review of body system (ROS) goals
for current health problems Plan to resolve the
Lifestyle & health practices
Developmental level problem
Listen, interpret & validate info Ask for further
Identify problem & goals question
COMMUNICATION DURING
INTERVIEW
VERBAL NONVERBAL
open – ended question
appearance
closed – ended
question demeanor
laundry list facial expression
rephrasing attitude
well – placed phrases silence
Inferring listening
Providing information
COMMUNICATION TO AVOID
VERBAL NONVERBAL
Biased or leading Excessive or
questions insufficient eye
Rushing through the contact
interview Distraction and
Reading the distance
questions Standing
SPECIAL CONSIDERATION IN
AN INTERVIEW
•Variations in communication
o Gerontologic
o Cultural
o Emotional
GERONTOLOGIC VARIATIONS
IN COMMUNICATION
do not approach an elderly client like having
a health problem
assess hearing acuity
speak slowly, face the client, position yourself near
the ear of the client with better acuity, do not yell at
the client
Older client may have more health concern
than young ones
older client with health problems feel
vulnerable and scared
GERONTOLOGIC VARIATIONS
IN COMMUNICATION
it is not unusual for elderly clients to be taken for
granted and their health complaints ignored,
causing them to become fearful of complaining
it is often disturbing to the older client that their
health problem may be discussed openly among
any healthcare provider and family members
assure the older client that you are concerned,
that you see them as equal partners in health care
and information are dealt with utmost
confidentiality
GERONTOLOGIC VARIATIONS
IN COMMUNICATION
speak clearly and use straightforward
language during the interview with the elderly
client
ask questions in simple terms. Avoid
medical jargon & modern slang. However, do
not talk down to the client
show respect at all times
GERONTOLOGIC VARIATIONS
IN COMMUNICATION
CULTURAL VARIATIONS IN
COMMUNICATION
reluctance to reveal personal information to
strangers
willingness to openly express emotional distress
or pain
ability to receive information
meaning conveyed by language
use and meaning of nonverbal communication
disease/ illness perception
past, present or future time orientation
family’s role in the decision making process
EMOTIONAL VARIATIONS IN
COMMUNICATION
scared and 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
have an ulterior motive for having an
assessment performed
have sensitive issues with which they are
grappling and may turn to you for help
INTERACTING WITH CLIENTS WITH
VARIOUS EMOTIONAL STATES
ANXIOUS CLIENT ANGRY CLIENT
o provide simple, organized o calm, reassuring, in – control
information in a structured manner
format o allow to ventilate feelings.
oExplain who you are and your However if the client is out of
role & purpose control do not argue or touch the
client
o Ask simple, concise questions o obtain help from other health
o Avoid becoming anxious like care professionals prn
the client o avoid arguing & facilitate
o do not hurry & decrease any personal space so the client does
external stimuli not feel threatened or cornered
INTERACTING CLIENTS WITH VARIOUS
EMOTIONAL STATE
DEPRESSED CLIENT MANIPULATIVE CLIENT
o express interest in and o Provide structure & set
understanding of the limits
client and respond in a o differentiate between
neutral manner manipulation & a
o do not try to reasonable request
communicate in an o if you are not sure
upbeat, encouraging whether your are being
manner. This will not manipulated, obtain an
help the depressed client objective opinion from
other nursing colleagues
INTERACTING WITH CLIENTS WITH
VARIOUS EMOTIONAL STATE
DISCUSSING SENSITIVE
SEDUCTIVE CLIENT
ISSUES
o set firm limits on overt o Be aware of your own
sexual client behaviour thoughts & feelings (dying,
spirituality, & sexuality) if
and avoid responding to necessary discuss with
subtle seductive someone
behaviors o ask simple in a non-
o encourage client to use judgemental manner
more appropriate o allow time for ventilation of
methods of coping in clients feelings prn
relating to others o if you are not comfortable &
competent make referral
COMPLETE HEALTH HISTORY
lays the groundwork for identifying nursing
problems and provides a focus for the physical
examination
provides information that will assist the examiner
in identifying areas of strength and limitation in the
individual’s lifestyle and current health status
provide cues to health problems that are most
apparent to the client
begin with an explanation to the client of why the
information is being requested
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. Review of body systems (ROS) for current health
problems
7. Lifestyle & health practices profile
8. Developmental level
BIOGRAPHIC DATA
identifying data & the name of the person providing the
information
client’s culture, ethnicity & subculture: date & place of
birth, nationality of ethnicity, marital status, religious or
spiritual practices, primary & secondary languages spoken,
written & read
educational level, occupation & working status: level of
understanding, identify strengths & limitations
identify support people & caregiver
when sharing information about the client, provide privacy
Primary source of data: patient; Secondary: SO & patient’s
medical record
REASON(S) FOR SEEKING
HEALTH CARE
What is your
major health • focus on the most significant
problem or health concern
• Chief complaints
concerns at
this time?
• Encourages the client to discuss
How do you fears or other feelings about having
feel about to see a health care provider
having to seek • Draw out descriptions of previous
experiences with other health care
health care? provider
HISTORY OF PRESENT HEALTH CONCERN
(PRESENT HEALTH HISTORY)
focused on the health problem
encourage to explain the health problem or
symptom in detail (onset, duration,
progression, s/s & related problem, client’s
perception causing the problem)
elicit what makes the problem worse or
better, which treatment have been tried,
effect of problem to daily life, expectations
about recovery & the ability of the client to
provide self – care
HISTORY OF PRESENT HEALTH CONERN
CONCERN (PRESENT HEALTH HISTORY)
Use mnemonic like COLDSPA
Character (What does the pain feel like?)
Onset (When did it begin?)
Location (Where is it? Does it radiate?)
Duration (How long does it last?)
Severity (How bad is it?)
Pattern (What makes it better or worse?)
Associated factors (What other symptoms
occur with it?)
ANALYZING THE HISTORY OF PRESENT
ILLNESS
1. Time of Onset- When was the first date (the
problem) happened? What time did it begin.
2. Type of on set - How did the problem start:
suddenly? gradually?
3. Original source- What where you doing when you
first experience or notice (the problem)?What seems
to trigger it; stress, position? certain activities?
Arguments? If describing a discharge; thick?runny?
clear?colored. If describing psychological problem; do
the voices drown out other sounds? Whose voices
does it sound like?
ANALYZING THE HISTORY OF PRESENT
ILLNESS
4. Severity- How bad is(the problem) when its at its
worst? Does it interfere with your normal activities? Does
it force you to lie down, sit down or slow down?
5. Radiation- In the case of pain, does it travel down you
back or arms, up your neck or down your legs?
6. Time relationship- How often do you experience (the
problem); hourly?daily?weekly monthly? When do you
usually experience it; day time?at night? In the early
morning?are you ever awaken by it?does it ever occur
before, during or after meals? Does it occur seasonally?
7. Duration- How long does an episode of (problem) last?
ANALYZING THE HISTORY OF PRESENT
ILLNESS
8. Course- Does (the problem) seem to be getting
better, to be getting worse, or does it remain the
same?
9. Association- Doe (the problem) lead to anything
else? Is it accompanied by other signs and
symptoms?
10. Source of relief- What relieves (the problem)
changing position? taking medications? being active)
11. Source of aggravation- What makes (the problem)
worse?
ANALYZING THE HISTORY OF PRESENT
ILLNESS
You Can Remember All The Questions Using the Letters PQRST
P= PROACTIVE/PALLATIVE
What causes it? What Makes it better? What makes it worse?
Q= QUALITY/QUANTITY
How does it fell, look, or sound, and how much of it is there?
R=REGION/RADIATION
Where is it? Does it spread?
S=SEVERITY SCALE
Does it interfere with activities? How does it rate
T=TIMING
When did it begin, How often does it occur? Is it sudden or
gradual?
PAST HISTORY
Ask your patient about the following:
1. Childhood and infectious diseases
2. Immunizations
3. Accidents
4. Surgical procedures
5. Allergies
6. Medications taken
FAMILY HEALTH HISTORY
assumes great importance in the incidence of
genetically based diseases
other health problem that may have affected
the client by virtue of having grown up in the
family and being exposed to health problems
like smoking
include as many genetic relatives as the
client recall
PERSONAL HEALTH HISTORY
focuses on questions related to the client’s
personal history, from the earliest beginnings to
the present
birth, growth & development
ask about childhood illnesses & immunization
adult illnesses including surgeries
prolong episodes of pain
allergies
intake of medication (prescribed, OTC)
PERSONAL HEALTH HISTORY
questions elicit data about the client’s
health history related to his or her strengths
and weaknesses
information gained assists in identifying risk
factors that stem from previous health
problems
LIFESTYLE AND HEALTH
PRACTICES PROFILE
it deals with the client’s human responses, which
include:
nutritional habits,
activity and exercise patterns,
sleep and rest patterns,
self concept and self – care activities,
social and community activities,
relationships,
values & beliefs system,
education and work,
stress level & coping style, and
environment
Thank You!!!
