Chapter 2

Collecting Subjective Data: The

Interview and Health History
Interviewing
In the preintroductory phase the nurse reviews the medical
record which may reveal the client's past health history and
reason for seeking health care before meeting with the
client to assist with conducting the interview.
❖ Phases of the interview
o Introductory
o Working
o Summary and closing

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Introductory Phase

❖ Introduction
❖ Explaining the purpose of the interview
❖ Discussing the types of questions that will be asked
❖ Explaining the reason for taking notes
❖ Assuring the client that confidential information will
remain confidential
❖ Making sure that the client is comfortable and has
privacy
❖ Developing trust and rapport using verbal and nonverbal
skills

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Working Phase #2
❖ 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

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Working Phase #3
❖ 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

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Summary and Closing Phase
❖ Summarizing information obtained during the working
phase
❖ Validating problems and goals with the client
❖ Identifying and discussing possible plans to resolve the
problem with the client
❖ Making sure to ask if anything else concerns the client
and if there are any further questions

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Question #1
Is the following statement true or false?
A client’s feelings and perceptions may be recorded as
subjective data.

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Answer to Question #1
True.
A client’s feelings and perceptions may be recorded as
subjective data.

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Nonverbal Communication

❖ Appearance
❖ Demeanor
❖ Facial expression
❖ Attitude
❖ Silence
❖ Listening

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Nonverbal Communication to Avoid

❖ Excessive or insufficient eye contact

❖ Distraction and distance
❖ Standing

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Verbal Communication

❖ Open-ended questions
❖ Closed-ended questions
❖ Laundry list
❖ Rephrasing
❖ Well-placed phrases
❖ Inferring
❖ Providing information

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Question #2
Is the following statement true or false?
The nurse should use closed-ended questions to elicit the
client’s feelings and perceptions.

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Answer to Question #2
False.
The nurse should use open-ended questions to elicit the
client’s feelings and perceptions. Closed-ended questions
should be used to obtain facts and to focus on specific
information.

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Verbal Communication to Avoid
❖ Biased or leading questions
❖ Rushing through the interview
❖ Reading the questions

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Special Considerations
❖ Gerontologic variations
❖ Cultural variations
❖ Emotional variations

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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.

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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.

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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.

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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.

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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

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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.

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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

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Health History—Biographical Data #1
❖ Name
❖ Address
❖ Phone
❖ Gender
❖ Provider of history (patient or other)
❖ Birth date
❖ Place of birth

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Health History—Biographical Data #2
❖ Race or ethnic background
❖ Primary and secondary languages (spoken and read)
❖ Marital status
❖ Religious or spiritual practices
❖ Educational level
❖ Occupation
❖ Significant others or support persons (availability)

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Question #3
Which sign in a genogram indicates adoption?
a. A horizontal dotted line
b. A vertical dotted line
c. An X in a circle
d. An X in a square

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Answer to Question #3
b. A vertical dotted line.
Rationale: In a genogram, a vertical dotted line may be
used to indicate adoption. A horizontal dotted line is used
to indicate the client’s spouse. An X in a circle indicates a
deceased female client. An X in a square indicates a
deceased male client.

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Review of Body Systems #1
❖ Skin, hair, nails
❖ Head, neck
❖ Eyes
❖ Ears
❖ Mouth, throat, nose, sinuses
❖ Thorax, lungs

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Review of Body Systems #2

❖ Breasts, regional lymphatics

❖ Heart, neck vessels
❖ Peripheral vascular
❖ Abdomen
❖ Genitalia
❖ Anus, rectum, prostate
❖ Musculoskeletal
❖ Neurologic

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Lifestyle and Health Practices #1

❖ Description of typical day (AM to PM)

❖ 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
❖ Rest and sleep habits and patterns
❖ Medication and substance use
❖ Self-concept and self-care responsibilities

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Lifestyle and Health Practices #2

❖ Social activities
❖ Relationships
❖ Values and belief system
❖ Past, present and future education and work
❖ Type of work, level of job satisfaction, work stressors
❖ Stress levels and coping strategies
❖ Residency, environment, neighborhood, environmental
risks

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