1

CHAPTER 2

COLLECTING
SUBJECTIVE DATA: THE
INTERVIEW AND
HEALTH HISTORY
COLLECTING SUBJECTIVE
DATA
Sensations or symptoms
Feelings
Perceptions
Desires
Preferences
Beliefs
Ideas
Values
Personal information
INTERVIEWING #1
• Requires professional, interpersonal, interviewing skills
• Two focuses:
• Establishing rapport and trusting relationship with client
• Gathering information on developmental, psychological,
physiologic, sociocultural, and spiritual status to identify
deviations and collaborative interventions or strengths that
can be enhanced
 4

INTERVIEWING #2
Phases of the interview:
• Preintroductory

• Introductory

• Working

• Summary and closing

PREINTRODUCTORY
PHASE
Nurse reviews medical record before meeting client.
Can reveal information that will help assess current needs
May reveal special considerations for interviewing client
Will guide nurse in obtaining necessary information
If no medical record in system, nurse will need to depend
on interviewing skills to elicit all necessary information.
INTRODUCTORY
PHASE
Introduction
Explain the purpose of the interview
Discuss the types of questions that will be asked
Explain the reason for taking notes
Assure the client that confidential information will remain
confidential
Make sure that the client is comfortable and has privacy
Develop trust and rapport using verbal and nonverbal
skills
 7

WORKING PHASE #1
Biographical 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
 8

WORKING PHASE #2
Listening, observing cues, and using critical
thinking skills to interpret and validate
information received from the client
Collaborating with the client to identify the
client’s problems and goals
SUMMARY AND CLOSING
PHASE
Summarize information
obtained during the
working phase
Validate problems and
goals with the client
Identify and discuss
possible plans to resolve
the problem with the
client
Make sure to ask if
anything else concerns the
client and if there are any
further questions
 10

🧠 THINK–PAIR–SHARE#1
Q1. In which phase does the nurse review the client’s chart before meeting them?

Q2. During which phase does the nurse gather details about past health history, family
history, and lifestyle practices?

Q3. Why is building trust and rapport in the introductory phase so important for collecting
subjective data?
NONVERBAL
COMMUNICATION
Appearance
Demeanor
Facial expression
Attitude
Silence
Listening
 12

NONVERBAL
COMMUNICATION TO
AVOID
Excessive or insufficient eye contact
Distraction and distance
Standing
VERBAL COMMUNICATION
• Open-ended questions
• Closed-ended questions
• Laundry list
• Rephrasing
• Well-placed phrases
• Inferring
• Providing information
 14

VERBAL COMMUNICATION TO AVOID

Biased or leading
questions
Rushing through the
interview
Reading the questions
 15

THINK–PAIR–SHARE:
• Q1. What are the three verbal communication
mistakes to avoid during an interview?
• Q2. Nurse asks: “When did the pain start? Was it
sharp? Did it get worse with movement?” — all at
once. What’s the issue?
• Q3. Why is it important for nurses to keep the
interview conversational instead of just “checking
off boxes”?
 16

SPECIAL
CONSIDERATIONS
DURING THE INTERVIEW
Gerontologic variations

Cultural variations

Emotional variations
 🔎 MISTAKE HUNT: WHAT
WENT WRONG?

Scenario 1: The nurse Scenario 2:

keeps strong, unbroken
While asking about the
eye contact the entire
client’s health history, the
interview. The client starts
nurse scrolls through the
looking away and shifting
chart on the computer and
uncomfortably.
avoids looking at the
👉 What went wrong?
client. The client gives
👉 How should the nurse
short, clipped answers.
adjust?
👉 What went wrong?
👉 How should the nurse
adjust?
 🔎 MISTAKE HUNT: WHAT
WENT WRONG?
Scenario 4
Scenario 3:
The client is sitting in a
The nurse asks: “You don’t
chair. The nurse remains
feel depressed, do you?”
standing while asking
The client quickly says,
questions. The client
“No.”
crosses arms and seems
👉 What went wrong?
disengaged.
👉 How should the nurse
👉 What went wrong?
adjust?
👉 How should the nurse
adjust?
 19

INTERACTING WITH AN ANXIOUS

CLIENT
• Provide the client with simple, organized
information in a structured format
• Explain who you are and your role and
purpose
• Ask simple, concise questions
• Avoid becoming anxious like the client
• Do not hurry
• Decrease any external stimuli
 20

INTERACTING WITH AN
ANGRY CLIENT
Approach the client in a calm, reassuring, in-
control manner
Allow the client to vent feelings
Avoid any arguments with or touching the
client
Obtain help from other health care
professionals as needed
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
 21

INTERACTING WITH A
DEPRESSED CLIENT
Express interest in and understanding of
the client and respond in a neutral manner
Take care not to communicate in an
upbeat, encouraging manner
 22

INTERACTING WITH A
MANIPULATIVE CLIENT
Provide structure and set limits
Differentiate between manipulation and a
reasonable request
Obtain an objective opinion from other
nursing colleagues
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
 24

DISCUSSING SENSITIVE ISSUES

Be aware of your own thoughts and feelings regarding dying, spirituality, and
sexuality

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
WORKING WITH
INTERPRETERS #1
Help interpreter adapt language to client’s level of speech
and comprehension
Help interpreter adapt communication for clients who cannot
communicate clearly
Help interpreter be aware of cultural language differences
Help interpreter be aware of other potential areas of cultural
variation
Help interpreter recognize memory problems and physical
distractions may elicit incorrect or insufficient information
 26

WORKING WITH
INTERPRETERS #2
• Help interpreter recognize other potential barriers to
communication
• Prior to interview
• Allow extra time for interpreting; determine if simultaneous or
consecutive mode of interpretation is to be used; encourage
interpreter to let you know of any communication problems
• During interview
• Introduce self and interpreter; sit looking directly at client;
watch client throughout interview; avoid technical jargon;
question client at end for any clarification, decisions, or
recommendations
 27

COMPLETE HEALTH HISTORY

Biographical data
Reasons for seeking health care
History of present health concern
Past health history
Family health history
Review of systems for current health problems
Lifestyle and health practices
Developmental level
This Photo by Unknown Author is licensed under
CC BY-NC-ND
 28

BIOGRAPHICAL DATA #1
• Name
• Address
• Phone number
• Gender
• Provider of history (client or other)
• Birth date
• Social Security number, medical record number, health insurance information, or
similar identifying data
 29

BIOGRAPHICAL DATA #2
• Culture, ethnicity, subculture
• Date and place of birth
• Nationality or ethnicity
• Marital status
• Religious or spiritual practices
• Primary and secondary languages (spoken, written, and read)
• Educational level
• Occupation; Working status
• Significant others or support persons (availability)
REASON(S) FOR
SEEKING HEALTH CARE
“What is your major health problem or concern at
this time?”
• Chief complaint
• Client focuses on most significant health concern.

“How do you feel about having to seek health

care?”
• Encourages client to discuss fears or other feelings about
having to see health care provider
HISTORY OF PRESENT
HEALTH CONCERN
Answers to questions provide detailed description of concern
Encourage detailed answers to questions
Use of various assessment tools assist in collecting necessary
data
Evaluate client’s insight into problem and plans for managing
it
Each identified symptom must be described for clear
understanding of probable cause and significance
COLDSPA
C: Character
O: Onset
L: Location
D: Duration
S: Severity
P: Pattern
A: Associated factors/how it affects the client
 33

PQRST PAIN ANALYSIS

MNEMONIC
P: Provocative/palliative
Q: Quality
R: Radiates
S: Severity
T: Timing
 34

PERSONAL HEALTH HISTORY

• Birth, growth, development
• Childhood diseases
• Immunizations
• Allergies
• Medication use: prescription, over the counter
• Previous health problems
• Hospitalizations, surgeries, pregnancies, births
• Previous accidents, injuries
• Pain experiences
• Emotional or psychiatric problems
 35

FAMILY HEALTH HISTORY

• A sample genogram is
illustrated in Figure 2-4
• Genogram of a 40-year-
old male client. CVA
(cerebrovascular
accident), HTN
(hypertension), NIDDM
(noninsulin dependent
diabetes mellitus)
 37

REVIEW OF SYSTEMS
FOR CURRENT HEALTH
PROBLEMS #1
Skin, hair, nails

Head, neck

Eyes

Ears

Mouth, throat, nose, sinuses

Thorax, lungs

Breasts, regional lymphatics

 38

REVIEW OF SYSTEMS
FOR CURRENT HEALTH
PROBLEMS #2
Heart, neck vessels

Peripheral vascular

Abdomen

Genitalia

Anus, rectum, prostate

Musculoskeletal

Neurologic
 39

LIFESTYLE AND
HEALTH
PRACTICES #1
Description of typical day
Nutrition and weight management
24-hour dietary intake (foods
and fluids)
Who purchases and prepares
meals
Activity on a typical day and
exercise habits and patterns
Sleep and rest
Substance use
Self-concept and self-care
responsibilities
LIFESTYLE AND HEALTH
PRACTICES #2
Social activities
Relationships
Values and belief system
Education and work
• Type of work, level of job
satisfaction, work
stressors
Stress levels and coping
strategies
This Photo by Unknown Author is licensed under
Environment CC BY-SA-NC

• Residency, neighborhood,
environmental risks