FIRST CITY

PROVIDENTIAL
COLLEGE
Narra, Francisco Homes, City of San Jose Del Monte, Bulacan

ACTIVITY D
SUBJECTIVE
INTERVIEWING AND RECORDING ASSESSMENT FINDINGS

QUESTIONS FINDINGS
Present History
Height?
Weight?
Fever?
Pain? (COLDSPA)

Allergies?
Present health concerns?
Past History
1. Weight gains or losses?
2. Previous high fevers, cause, and treatment?

3. History of abnormal pulse?

4. History of abnormal respiratory rate or
character?

5. Usual blood pressure, who checked it last?,

and when?

6. History of pain and treatment?

Family History
1. Hypertension?

2. Metabolic / Growth problems?

Lifestyle and Health Practices

1. Religious affiliation?
 FIRST CITY
PROVIDENTIAL
COLLEGE
Narra, Francisco Homes, City of San Jose Del Monte, Bulacan

ACTIVITY D
OBJECTIVE
INTERVIEWING AND RECORDING ASSESSMENT FINDINGS

QUESTIONS FINDINGS
Overall Impression of the Client:
1. observe physical development (appears to
be chronologic age) and sexual development
(appropriate for gender and age)
2. observe skin (generalized color, color
variation, and condition)
3. observe dress (occasion and weather
appropriate)
4. Observe hygiene (cleanliness, odor,
grooming)
5. Observe posture ( erect and comfortable)
and gait (rhythmic and coordinated)
6. Observe body build ( muscle mass and fat
distribution)
7. Observe consciousness level (alertness,
orientation, appropriateness )
8. Observe comfort level
9. Observe behavior ( body movements,
affect, cooperativeness, purposefulness, and
appropriateness)
10. Observe facial expression (culture-
appropriate, eye contact, and facial
expression)
11. Observe speech ( pattern and style )
Vital Signs
1. Gather equipment (thermometer,
sphygmomanometer, stethoscope, and watch)
2. Measure temperature (oral , axillary, rectal,
tympanic)
3. Measure radial pulse (rate, rhythm,
amplitude, contour, and elasticity)
4. Measure blood pressure
Analysis of Data
1. Formulate nursing diagnoses (wellness,
risk, actual)
2. Formulate collaborative problems
3. Make necessary referrals