Nursing Interview and General Survey

Good morning Maam! Iam Andro L Estal a 1st year student Nurse from Davao
Doctors College. And today I will be performing a return demonstration in Nursing
Interview and General Survey.
Pre introductory phase
Before the interview we must….
Reviewed clients previous medical records if available. Prepare the necessary
equipment.
And the most important is to perform hand washing.
Introductory Phase
Greeted the client politely (and client's companion if around)
-Good morning Maam/Sir.
Introduced self and verified the client's identity.
-I am Andro Estal your student nurse for today. . May know your complete name
maam/sir. And your birthdate.
Asked how the client would like to be called during the assessment
-How would you like me to call you?
Explained the purpose and objective of the interview, the type of questions to be
asked, and reason for taking notes.
-Before getting any further id like to let you know that in order for me help you today
I need to ask you some questions particularly about your health and medical
background and some of your personal circumstance.
Is that alright with you?
So your answers will be documented so that we will able to formulate the best care
that will suit you need.
Assessed for any potential barriers to communiation (ex. patient's age,language
and ability to speak, literacy level, ability to hear, etc.)
-What specific language you prefer using, during the assessment?
May I ask if you can clearly hear Maam/sir?
Provided the client the opportunity to clarify, ask or raise any concern.
-Do you have any questions or clarifications Maam/Sir.
Working Phase
Began the interview with open-ended questions that allowed full freedom of
response.
Biographic Data
-I would like to verify some of your informations maam/sir. NAME, SEX, BDATE
AND ADDRESS.
Reason for seeking care
May I ask what brings you here today?
C- Can you describe your (sakit).
O- When did the pain start? How long does it last?
L- Does it radiate? Does it occur anywhere else?
D- How long does it last?
S- How would you rate your pain on a scale of 0 to 10, with “0” being no pain and
“10” being the worst pain you’ve ever experienced?
P- What makes it better or worse?
A- What other symptoms occur with the (sakit)? How does it affect you?
Past health history
Had you ever been admitted in the hospital before for any health problems?
Have you ever had a major illness? 
Have you ever had a major injury? 
Have you ever had major surgery / a major operation? 
Do you have any allergies? / Are you allergic to anything?
Gynecologic and Obstetric history (if babae ang patient)
When was the last menstration period ?
Is that normal or irregular?
Family History
Do you know any health problems in any member of your family?
Have you been exposed to any member in your family with fever,cough or any other
illness?
Psychosocial History
How often do you communicate with your friends?
When you have problems does your friends help you?
Current Lifestyle
Do you have a proper diet?
Do you exercise?
Do you smoke at all?
Do you drink any alcohol?
Are you happy in your life?
SUMMARY AND CLOSING PHASE
Summarized the information obtained during the working phase.
-These are the subjective data I had from the interview. (SUMMARIZE ANG MGA
SAKIT)
-(After pag summarize ng data)
Discussed to the client possible plans to resolve health concern.
Did I miss anything? Does everything I said is correct?
Assessed for client's understanding of the plan and the need for further
teaching.
-I'll let Dr. Andro know about your health issue. so that he can administer medication
to treat your health issue.
-I have already informed Dr. Andro of your health issue, and we will wait for his
prescription.
Provided the client the opportunity to clarify, ask or raise any concern.
-Do you have any questions or clarifications Maam? If none thank you for your full
cooperation Maam/Sir.
-PERFORM HANDWASHING
Good morning everyone. Iam Andro Estal BSN1 11E Group 18.
and today im assessing a patients skin. Skin is the largest organ
in our body and the first line defense of our body against the
invasion of microorganisms.
Good morning maam Im Andro L Estal a 1st first year student
nurse from davao doctors college. May I see your wrist band
maam. Please state your complete name. And your bdate please.
How would you like me to call you. So andro im going to be
inspecting and palpating your hair skin and nails to check any
lesions or skin changes that may give us insight of your current
health status.. and before that im gonna need to ask you just a
few questions regarding your health history so that will be able
to give you best care that suit you need. Will that be alright
ANDRO? Do you have any questions or clarifications before im
going to start the assessment?
So Andro are you currently experiencing any skin problems like
do you have any rashes lesions or skin changes you noticed.
When did you first notice it?
What do you think happened to that, how do you think did you
get that?
What did you do? Did you apply any ointment on it or take
medications?
Do you have any other health issues aside from that one?
Do you have other skin disease or diabetes or respiratory
problems?
Is there any health disease that affect your family?
Do you have allergy?
AND NOW WERE DONE WITH QUESTIONS , SO NOW
ILL BEGIN ASSESSING YOUR SKIN
Ill start from your head , just check for other lesions,IST OKAY
TO TOUCH ANY PART OF YOUR BODY SO I CAN
PROPERLY ASSESS?
so generally I see that your skin is consistent all over, and i
don’t see any unusual discoloration. And now let me see your
hair.
INSPECT USING RULER!
So basically im just looking for any scars or lotion which you
don’t have, skin is intact, okay and I don’t see any headlights or
dandruff. Hair moisture is good and as well as texture.
Lets move on to your face. I see your hair is evenly distributed
in your scalp and in your eyebrows and eyelashes as well. And
you’ve got two ear piercings.
Lets move on to your neck. Kung may MOLES,
these moles have it been there for a while or did just pop up?
And you havent noticed any odd moles in your body?
Neck is good I don’t see any discoloration. So lets check for
your skin surgery I just need to pinch slightly your skin here on
top of your collarbone ill note that your skin trigger is elastic
because it went back to its place after I lightly pinch it which
indicates that you are well hydrated
Lets move on to your back
Pag way rashes na yakita; All right I don’t see anything any
rashes and lesions so back and neck is clear.