Nursing Interview Guide to Collect Subjective Data From the Client

NAME:

QUESTIONS FINDINGS

Biographic Data

1. Name?

2. Address?

3. Phone?

4. Birth date?

5. Provider History?

6. Ethnicity?

7. Educational level?

8. Occupation?

Nursing Interview Guide to Collect Subjective Data From the Client (continue)

QUESTIONS FINDINGS

Current Symptoms

1. History of present concern (COLDSPA)?

Past History

1. Birth problems?

2. Childhood ilillnesses?

3. Immunizations?

4. Illnesses?
 5. Surgeries?

6. Accidents?

7. Pain?

8. Allergies?

Family History

1. Family Genogram?

Preview of Body Systems

1. Skin, hair, nails?

2. Ears?

3. Mouth, throat, nose, sinuses?

4. Thorax and lungs?

5. Breasts and regional lymph nodes?

6. Heart and neck vessels?

7. Peripheral vascular?

8. Abdomen?

9. Male/female genitalia?
 10. Anus, rectum, and prostate?

11. Musculoskeletal?

12. Neurologic?

Lifestyle and Health Practices

1. ADLs in a typical day?

2. Diet for past 24 hours?

3. Exercise regimen?

4. Sleep patterns?

5. Medications?

6. Use of recreation drugs, alcohol, nicotine,

or caffeine?

7. Self-concept?

8. Life stressors and coping strategies?

9. Responsibilities and role at home and at

work?

10. Type of work and level of satisfaction?

 11. Finances?

12. Educational plans?

13. Social activities?

14. Relationships with others?

15. Values?

16. Spirituality?

17. Religious affiliations?

18. Environment, residency, and

neighborhood?

Physical Assessment Guide to Collect Objective Client Data

QUESTIONS FINDINGS

1. Gather all equipment needed for a head-

to-toe exam.

2. Prepare client by explaining what you will

be doing.

General Survey

1. Observe appearance.

2. Assess vital signs.

 3. Take body measurements.

4. Calculate ideal body weight, body mass

index, waist-to-hip ratio, mid-arm muscle
area and circumference.

5. Test vision.

Mental Status Examination

1. Observe LOC.

2. Observe posture and body movements.

3. Observe facial expressions.

4. Observe speech.

5. Observe mood, feelings, and expressions.

6. Observe thought processes and

perceptions.

7. Assess cognitive abilities.

8. Give client a specimen cup if sample is

needed, and ask client to empty bladder
and change into gown. Ask client to sit on
examination table.

Skin
 1. Throughout examination, assess skin for
color variations, texture, temperature,
turgor, edema, and lesions.

2. Teach skin self-examination.

Head and Face

1. Inspect and palpate head.

2. Note consistency, distribution, color of

hair.

3. Observe face for symmetry, features,

expressions, condition of skin.

4. Have client smile, frown, show teeth,

blow out cheeks, raise eyebrows, and
tightly close eyes (CN VII).

5. Test sensations of forehead, cheeks, and

chin (CN V).

6. Palpate temporal arteries for elasticity

and tenderness.

7. Palpate temporomandibular joint.

Eyes

1. Assess visual function.

2. Inspect external eye.

 3. Test papillary reaction to lights.

4. Test accomodation of pupils.

5. Assess corneal reflex (CN VII facial).

6. Use ophthalmoscope to inspect interior

of eye.

Ears

1. Inspect auricle, tragus, and lobule.

2. Palpate auricle and mastoid process.

3. Use otoscope to inspect auditory canal.

4. Use otoscope to inspect tympanic

membrane.

5. Test hearing.

Nose and Sinuses

1. Inspect external nose.

2. Palpate external nose for tenderness.

3. Check patency of airflow through nostrils.

4. Occlude each nostril and ask client to

smell for soap, coffee, or vanilla (CN I).
 5. Use otoscope to inspect internal nose.

6. Transilluminate maxillary sinuses.

Mouth and Throat

1. Put on gloves.

2. Inspect lips.

3. Inspect teeth.

4. Check gums and buccal mucosa.

5. Inspect hard and soft palates.

6. Observe uvula.

7. Assess for gag reflex (CN X).

8. Inspect tonsils.

9. Inspect and palpate tongue.

10. Assess tongue strength (CN IX and X).

11. Check taste sensation (CN VII and IX).

Neck

1. Inspect appearance of neck.

 2. Test ROM of neck.

3. Palpate preauricular, postauricular,

occipital, tonsillar, submandibular, and
submental nodes.

4. Palpate trachea.

5. Palpate thyroid gland.

6. If enlarged, auscultate thyroid gland for

bruits.

7. Palpate and auscultate carotid arteries.

Arms, Hands, and Fingers

1. Inspect upper extremities.

2. Test shoulder shrug and ability to turn

head against resistance (CN XI spinal).

3. Palpate arms.

4. Assess epitrochlear lymph nodes.

5. Test ROM of elbows.

6. Palpate brachial pulse.

7. Palpate ulnar and radial pulses.

 8. Test ROM of wrist.

9. Inspect and palpate palms of hands.

10. Test ROM of fingers.

11. Use reflex hammer to test biceps, triceps,

and brachioradialis reflexes.

12. Test rapid alternating movements of

hands.

13. Test sensation in arms, hands, and

fingers.

Posterior and Lateral Chest

1. Ask the client to continue sitting with

arms at sides and stands behind the
client. Untie gown to expose posterior
chest.

2. Inspect scapulae and chest wall.

3. Note the use of accessory muscles when

breathing.

4. Palpate chest.
5. Evaluate chest expansion at T9 or T10.

6. Percuss at posterior intercostal spaces.

7. Determine diaphragmatic excursion.

 8. Auscultate posterior chest.

9. Test for two-point discrimination on back.

10. Auscultate apex qnd left sternal border of

heart during exhalation.

Anterior Chest

1. Inspect chest.

2. Note quality and pattern of respirations.

3. Observe intercostal spaces.

4. Palpate anterior chest.

5. Percuss anterior chest.

6. Auscultate anterior chest.

7. Test skin mobility and turgor.

8. Ask client to fold gown to waist and sit

with arms hanging freely.

Female Breasts

1. Inspect both breasts, areolas, and

nipples.

2. Inspect for retractions and dumpling of

nipples.
 3. Palpate axillae.

Male Breasts

1. Inspect breast tissue.

2. Palpate breast tissue and axillae.

3. Assist client to supine position with the

head elevated to 30 to 45 degrees. Stand
on client's right side.

Neck

1. Evaluate jugular venous pressure.

2. Assist client to supine position (lower

examination table).

Breasts (Female)

1. Palpate breasts for masses and nipples

for discharge.

2. Teach breast self-examination.

Heart

1. Inspect and palpate for apical impulse.

2. Palpate the apex, left sternal border, and

base of the heart.

3. Auscultate over aortic area, pulmonic

area, Erb point, tricuspid area, and apex.
 4. Auscultate apex of heart as client lays on
left side.

Abdomen

1. Cover chest with gown and arrange

draping to expose abdomen.

2. Inspect abdomen.

3. Auscultate abdomen.

4. Percuss abdomen.
5. Palpate abdomen.

Legs, Feet, and Toes

1. Observe muscles.

2. Note hair distribution.

3. Palpate joints of hips and test ROM.

4. Palpate legs and feet.

5. Palpate knees.

6. Palpate ankles.

7. Assess capillary refill.

8. Test sensations (dull and sharp), two-

point discrimination, reflexes, position
 sense, and vibratory sensation.

9. Perform heel-to-shin test.

10. Perform any special test as warranted.

11. Secure gown and assist client to standing

position.

Musculoskeletal and Neurologic Systems

1. Observe for spinal curvatures and check

for scoliosis.

2. Observe gait.

3. Observe tandem walk.

4. Observe hopping on each leg.

5. Perform Romberg test.

6. Perform finger-to-nose test.

Female Genitalia

1. Have the female client assume the

lithotomy position. Apply gloves. Apply
lubricant as appropriate.

2. Inspect pubic hair.

3. Inspect mons pubis, labia majora, and

 perineum.

4. Inspect labia minora, clitoris, urethral

meatus, and vaginal opening.

5. Palpate Bartholin glands, urethra, and

Skene glands.

6. Inspect cervix.

7. Inspect vagina.

8. Obtain cytologic smears and culture.

9. Palpate cervix.

10. Palpate uterus.

11. Palpate ovaries.

12. Discard gloves and apply clean gloves and

lubricant.

13. Palpate rectovaginal septum.

Male Genitalia

1. Sit on a stool and have the client stand

and face you with gown raised. Apply
gloves.

2. Inspect penis.
 3. Palpate for urethral discharge.

4. Inspect scrotum.

5. Palpate both testis and epididymis.

6. Transilluminate scrotal contents.

7. Inspect for bulges in inguinal and femoral

areas.

8. Palpate for scrotal hernia.

9. Palpate for inguinal hernia.

10. Teach testicular self-examination.

11. Inspect perineal area.

12. Inspect sacrococcygeal area.

13. Inspect for bulges or lesions as Valsalva

maneuver is performed.

Rectal

1. Ask the client to remain standing and to

bend over the exam table. Change gloves.

2. Palpate anus.

3. Palpate external sphincter.

4. Palpate rectum.

5. Palpate peritoneal cavity.

6. Palpate prostate.

7. Inspect stool.