COLLECTING SUBJECTIVE DATA

Health Assessment
DR. REGIE P. DE JESUS
 Purpose of Assessment
• To establish baseline information on
the client
• To determine the client’s normal
function
• To determine the client’s risk for
diagnosis function
• To provide data for the diagnostic
phase
 THE PURPOSE
OF ASSESSMENT

• To organize a database regarding a client’s

physical, psychosocial, and emotional health.
• To identify health-promoting behaviors and
actual and/or potential health problems.
 Types of Assessment
• 1. Initial Assessment – performed
within specified time after
admission to a health care agency
– The purpose is to establish complete
database for problem identification
and care planning
– E.g. Nursing Admission Assessment
• 2. Problem-Focused Assessment –
ongoing process integrated with
nursing care to determine specific
problem identified in an earlier
assessment and to identify new or
overlooked problems
– E.g. Assessment of client’s ability to
perform self-care while assisting client
to bathe.
• 3. Emergency Assessment – done during
psychiatric or physiological crisis of the client
to identify life threatening problems
– E.g. Rapid assessment or airway, breathing and
circulation during cardiac arrest.
– A nursing-home resident who begins choking in
the dining room
– A bleeding patient brought to the emergency
room with a stab wound
• 4. Time-Lapsed Assessment – done
several months (scheduled) after
initial assessment to compare the
client’s status to baseline data
previously obtained
– E.g. Patients receiving nursing care
over long periods of time
 TYPES OF DATA
a. Subjective data
• Subjective data–data from client’s point of
view, and include perceptions, feelings, and
concerns. Collected by interview.
• Also referred to as SYMPTOMS or COVERT
data, apparent only to the person affected,
can be verified only by that person
– E.g itching, pain, feelings of worry, nausea
 b. Objective Data
• Objective data–observable and measurable,
obtained through both physical examination
and the results of lab and diagnostic testing
• Also referred to as SIGNS or OVERT data
• Can be seen, heard, smelled, or felt by
someone other than the patient
– E.g. Blood pressure, temperature, pulse rate, foul
smelling wound drainage
 Sources of Data
• Primary source
– The client
• Secondary sources
– All other sources of data (support
people, records, other health care
professionals, literature)
– Should be validated, if possible
 Data Collection Methods
• Observation

• Interviewing

• Physical Assessment
 Interviewing
• Interviewing
– Interview - planned communication or
a conversation with a purpose
– Used to:
• Get or give information
• Identify problems of mutual concern
• Evaluate change
• Teach
• Provide support
• Provide counseling or therapy
 Directive Approach to
Interviewing
• Nurse establishes purpose
• Nurse controls the interview
• Used to gather and give information
when time is limited, e.g., in an
emergency
 Nondirective Approach to
Interviewing
• Rapport-building
• Client controls the purpose, subject
matter, and pacing
• Combination of directive and
nondirective approaches is usually
appropriate during information-
gathering interview
 Types of Interview
Questions
• Closed questions
– Restrictive
• Yes/no
• Factual
– Less effort and information from client
– “What medications did you take?”
– “Are you having pain now?”
 Types of Interview
Questions (cont’d)
• Open-ended questions
– Specify broad topic to discuss
– Invite longer answers
– Get more information from client
– Useful to change topics and elicit
attitudes
• Neutral question
• Leading question
 Neutral Questions
• uestion the client can answer with-
out direction or pressure from the
nurse, is open ended, and is used in
nondirective interviews.
• Examples are “How do you feel
about that?” “What do you think
led to the operation?”
 Leading Questions
• Are those that suggest a particular
answer
• used in a directive interview, and
thus directs the client’s answer.
• E.g.
– You do not miss any doses of your
medication, do you?
– So you’ve had sex with someone other
than your boyfriend recently, have you?
 Factors in Interview
Setting
• Time
– Client free of pain
– Limited interruptions
• Place
– Private
– Comfortable environment
– Limited distractions
 Factors in Interview
Setting (cont’d)
• Seating arrangement
– When a client is in bed, the nurse can sit
at a 45-degree angle to the bed. This
position is less formal than sitting behind
a table or standing at the foot of the bed.
– In group interview, circular or horseshoe
arrangement is best.
• Distance
– Comfortable
 Distance
• Intimate: up to 18 inches from
another person
• Personal: 1 ½ to 4 feet away. The
distance most frequently used for
interviews
• Social: 4 to 12 feet away
• Public: > 12 feet away
 Factors in Interview
Setting (cont'd)
• Language
– Use easily understood terms
– Interpreter or translator
 Some productive
communication patterns…
1. Opening questions: “Tell me about…”
2. Reflection: Repeating the patient’s key statements
3. Clarification: “What do you mean by…”
4. Empathetic responses: Show understanding and
acceptance
5. Confrontation: Make observations “You appear to…”
6. Interpretation: “Do I understand you to be saying…”
7. Silence
8. Direct questions
9. Summary
 Interview Stages
• Opening – establish rapport, orient client
• Body – client communicates, nurse asks
questions
• Closing – nurse ends interview when
necessary information is collected
• Phases
– Pre-interaction,
– Initial interview.
– Focused interview
 Procedure and Notations
• Always Review Chart Before Seeing
Patient Note: The interview guides the
focus of the physical assessment process.
 
• Dress appropriately. How you look
communications either respect or
disrespect for and toward the interviewee.
Judgments are made (rightly or wrongly)
based on appearance. When in doubt,
wear what there is no doubt about.
 Environment for interview
1. Sit down in clear view of patient, preferably at eye
level.
2. Distance of 1 ½ to 4 feet (personal distance most
frequently used for interview).
3. Have patient sit next to desk rather than peer over
desk (as if over a barrier). Or it on two chairs
placed at right angles
4. Put the chart to the side if possible. The chart
itself can be a barrier between you and the
patient.
5. If you need to take notes explain this to the
patient.
 Comprehensive Health
History
• Health history provides a
comprehensive portrait of the pt’s
past and present health.
• Components are as follows:
– Biographic/Demographic Dats
– Reason for Seeking Care (Chief Complaint)
– Present Health or hx of present illness
– Current medications
– Family History
– Review of Sysems
 Demographic Data
• Name
• Address and phone number
• Age and birth date
• Birthplace
• Gender
• Marital status
• Race, ethnic origin
• Occupation
 Reasons for Seeking Care
(Chief Complaint)
• This is a brief spontaneous statement
in the pt’s own words that describes
the reason for the visit
• It states one (possibly two) signs or
symptoms and their duration
• It is not a diagnostic statement
• Reason for seeking care – because it
incorporates wellness needs
• Sign – an objective abnormality that can be
detected on physical examination or in
laboratory studies
• Symptom – a subjective sensation that the
person feels from the disorder
• It is enclosed in quotation marks to indicate
the person’s exact words.
• Example
• “I had dizziness and ringing of the right ear”
as verbalized by the pt.
 History of Present Illness
• For the well person, this is a short
statement about general state of health
• For the ill person, this is a chronological
record of the reason for seeking care, from
the time the symptom first started until
now (describes information relevant to C.C.)
• E.g. “Please tell me all about your headache,
from the time it started until the time you
came to the hospital.”
History of Present Concern
 Memory-mnemonic
COLDSPA
• C haracter: describe the sign/symptom. How does it feel
(sharp, dull, aching, throbbing), look (shiny, bumpy, red
swollen, bruised), sound (loud, soft, rasping), smell (foul,
sweet, pungent.
• O nset: When did it begin?
• L ocation: Where is it? Does it radiate?
• D uration: How long does it last? Does it recur?
• S everity: How bad is it?
• P attern: What makes it better? worse?
• A ssociated factors: What other symptoms occur with it?
 Memory-mnemonic

PQRST
a. Provocative factors
b. Quality  
c. Radiation/ Region (Location)
d. Severity of pain
e. Timing
 Memory-mnemonic
OLDCART
• Onset
• Location
• Duration
• Character (quantity, quality)
• Associated manifestations (setting,
symptoms)
• Relieving/aggravating Factors
• Treatment
 Sample
• Five days prior to admission (PTA), patient
developed intermittent fever, headache, chills and
generalized body malaise. She then took Paracetamol at
standard dosages (500mg, TID) on her own as advised by
her mother. Fever had been on and off in the next 3 days.
1 day prior to admission, after minimal obliteration in fever
and headache, she had diffuse abdominal pain with a scale
of 7/10, repeated vomiting and diarrhea accompanied by
nose bleeding. On the day of admission , patient continued
to have episodes of the said symptoms and these alarmed
the patient’s parents. Few hours PTA, numerous rashes on
the arms were noted by her parents thus seeking medical
attention. On the evaluation in the emergency
department, a few additional rashes were observed,
evidence of spontaneous bleeding hence admission
 Past Health History
• Past health events may have residual
effects on the current state of health
• Previous experience with illness may
give clues on how the pt responds to
illness and to the significance of illness
for him or her
• Include: date, problem, hospitalizations,
symptoms, treatment, current status –
ongoing? resolved?
Past Health History
 Past Health History
1. Previous experience with illness, childhood illness?
– Immunizations – diphtheria, tetanus, pertussis,
rubella, measles, mumps, polio, TB, hepatitis,
varicella, etc.
– Allergies – Ask: Any allergies to food, drugs,
pollen, beestings, clothing, chemicals, animals
or anything in environment? Note both the
allergen and the reaction (rash, itching, runny
nose, watery eyes, difficulty breathing).
– Include illnesses not requiring hospitalization
• Childhood Illnesses – Measles, mumps,
rubella, chicken pox, pertussis, and
strep throat
• Serious or Chronic Illnesses – Diabetes
Mellitus, Hypertension, heart disease,
cancer, seizure disorder
• Hospitalizations – Cause, name of
hospital, how the condition was treated
and how long the person was
hospitalized
 Past Health History
2. Surgical history: include dates,
problem, where occurred, where
operation performed, complications?
– ask about tonsils, adenoids and
appendectomy?
– ask about blood transfusions, reactions?

3. Injuries/accidents? Treated in ED?

– Accidents or Injuries – auto accidents,
head injuries, burns, falls
• Surgery/Operations – type of surgery,
date, name of the hospital, and how
the person recovered
• Obstetric History – Number of
pregnancies (gravidity), number of
deliveries in w/c the fetus reached full
term, number of preterm
pregnancies, number of abortions and
number of children living
• Gravida_____, Term ______,
Preterm_____, Abortion _____,
Living_____
 Past Health History
• Medications/pills of any type – taken
regularly?
– prescribed by physician?
– self-prescribed?
– BCP? Vitamins?

 Last Examination Date: physical, dental,

vision, hearing, electroencephalogram
(ECG), Chest X-ray
 Family Health History
• Ask about the age & health or age and
cause of death of blood relatives such
as parents, grandparents, siblings.
• Ask about close family members such
as spouse & children, if there is
prolonged contact with any
communicable diseases
• Discover more health problems that
seem to run in families, but are
genetically based (e.g., smoking, obesity, HD,
HTN, arthritis, thyroid disorders, DM, alcoholism, myopia,
learning disability, cancer, etc.)

• Genogram: a standard format used

to represent client’s family history
(you have to make a genogram of
your family with you as the patient)
Family Health History
 Current Medications
• Note all prescription and over-the-
counter medications and herbal remidies
• Ask specifically for vitamins, birth control
pills, aspirin, antacids
• For each medication, note the name,
dose, & schedule & ask, “How often do
you take it each day?” “ What is it for?”
and “How long have you been taking it?”
 Review of Systems (ROS)
• Each body system is addressed, client is
asked questions to draw out current health
problems or problems in the recent past to
that may still affect the client or are
recurring.
• The order of the examination is from head
to toe.
• Only client’s subjective info & not examiner’s
objective observations
• Q about S/S should be asked in terms that
the client understands & recorded in
standard medical terminology
• Typically asked as closed‐ended questions
(yes/no)
• Generally move from head to toe when
asking questions
 ROS for current health problems

• Skin, hair, nails

• H&N
• EENT
• Thorax & lungs
• Breast & regional lymphatics
• PV
• Abdomen
• Genitalia
• Anus, rectum, prostate
• Musculoskeletal
• neurologic
Review of Systems (ROS)
• General (ask about sleep, appetite, weight changes, fatigue,
fever/chills/night sweats, if clothes fit differently lately, etc)
• Skin (ask about rashes, hives, lumps, sores, itching, dryness,
recent changes in skin/hair/nails, etc)
•  Eyes (ask about vision issues, recent changes in vision, blurriness,
double vision (diplopia), blind spots, last eye exam, ocular pain,
photophobia, etc)
• Ears (ask about hearing, hearing aid, recent changes in hearing,
ringing in ears (tinnitus), dizziness (vertigo), ear pain, drainage,
etc)
• Nose (ask about stuffiness, runny nose (rhinorrhea), postnasal
drip, itching, dryness, bleeding (epistaxis), sinus pain, reduced or
enhanced sense of smell, etc)
• Mouth/throat (ask about issues with teeth/gums, bleeding gums,
frequency of visiting dentist, sores on tongue, mouth or lips, fever
blisters/cold sores, canker sores, thrush, tonsillitis, frequent sore
throats, hoarseness/voice changes, etc)
Review of Systems (ROS)
• Chest/pulmonary (ask about coughing, sputum (including color,
quantity), dyspnea, chest pain, coughing up blood (hemoptysis),
wheezing, dyspnea on exertion, orthopnea, last CXR, etc)
• Breast (ask about lumps, pain/discomfort/tenderness, self‐
examination, last clinical exam/mammogram, etc)
• Cardiac (ask about cyanosis, syncope, chest pain / discomfort,
palpitations, edema, last EKG, etc)
• GI (ask about abdominal pain, not wanting to eat (anorexia), N/V,
diarrhea, constipation, change in bowel habits/appearance,
dysphagia, odynophagia, heart burn, regurgitation, vomiting
blood (hematemesis), indigestion/bloating, gas, melena, etc)
• GU (ask about change in frequency/volume of urine, polyuria,
nocturia, pain/burning on urination, flank pain, hematuria,
urgency, straining, incontinence, change in color/odor, genital
discharge, sores, any other related issues with genitalia, etc)
• Musculoskeletal (ask about muscle pain/tenderness, backache,
joint pain/swelling, tenderness/heat, etc)
Review of Systems (ROS)
• Hematology (ask about easy bruising/bleeding, bleeding gums,
blood clots, transfusions, etc)
• Vascular (ask about color changes in fingers/toes from cold
temperature, leg cramps, edema, loss of hair on extremities, cool
extremities, discoloration of extremities, leg ulcers, varicose veins,
• Neurological / Head (ask about dizziness, headache,
blackouts/fainting (syncope), seizures, weakness, paralysis,
numbness/tingling (paresthesia), burning sensations, trembling,
pain when moving/walking, ability to walk/ steadiness, memory
loss, difficulty concentrating, behavioral changes, etc)
• Endocrine (ask about thyroid/goiter, recent heat/cold intolerance,
excessive sweating, excessive thirst/hunger, polyuria, change in
hair distribution/coarseness, breast changes, change in
hat/glove/shoe size (i.e. with Paget’s Disease), etc)
• Psychiatric (ask about treatment for psychiatric/emotional
distress, nervousness/anxiety, mood, personality
• changes, insomnia, hallucinations/delusions, etc)
Personal/ Social History
Personal/ Social History
Personal/ Social History
DESCRIPTION OF A TYPICAL DAY
• Start with awakening in
the morning & continue
until bedtime
• It provides the
orientation from which
the day is viewed
• For most people it
includes work & school
 NUTRITION & WEIGHT
MANAGEMENT
•What do you usually eat during a
typical day?
•Please tell me the kind of foods you
prefer, how often you eat
throughout the day, & how much
you eat.
•Do you eat out at restaurants
frequently?
•Do you eat only when you are
hungry?
•Do you eat because of boredom,
habit , anxiety or depression?
•Who buys & prepares the food you
eat?
•Where do you eat your meals?
•How much & what type of fluids do
you eat?
 Activity level &
Exercise
•What is your daily pattern
of activity?
•Do you follow a regular
exercise plan?
•What types of exercises do
you do?
•Are there any reasons why
you can’t follow a
moderately strenuous
exercise program?
•What do you do for leisure
& recreation?
•Do your leisure &
recreational activities include
exercise?
Sleep & Rest
•Tell me about you sleeping
patterns.
•Do you have problems
falling asleep or staying
asleep?
•How much sleep do you
get each night?
•Do you feel rested when
you are awaken?
•Do you nap during the
day?
•How often & for how long?
•What do you do to help
you fall asleep?
Medication &
Substance Abuse
•What medications do you
used in the recent past &
currently, both those that
you doctor prescribed &
those that you can buy over
the counter at a drug or
grocery store?
•Do you take vitamins or
herbal supplements?
• Do you now or have
you ever have
smoked cigarettes or
used any form of
nicotine?
• Have you ever use or
do you now used
recreational drugs?
Self-concept,
Self-care
(sexual responsibility,
basic hygiene practices,
regularity of health care
check-ups, accident
prevention & hazard
protection)
•How do you promote
your health?
•How do you feel about
yourself?
•What do you see as your
talents or special abilities?
 Values & Beliefs
(philosophical, religious, spiritual
beliefs; feelings should be
respected)
•What is most important to you
in life?
•What do you hope to
accomplish in life?
•Do you have religious
affiliation..importance?
•What gives you strength &
hope?
•Is a relationship with God an
important part of your life?
Social Activities
(beyond family & work)
•What do you do for fun &
relaxation?
•With whom do you socialize
frequently?
•How do you feel about your
community?
Relationships
(significant others)
•Who…the most important
person…life?
•What was it like growing in
your family?
•What is the relationship
with your spouse…children…
in-laws…significant others?
•What’s your role in your
family?
•Do you have pets?
•Are you satisfied with your
current sexual
relationships…changes?
Education &
Work
•What is like getting an
education?
•Are you satisfied with…
education..you have…
future educational plans?
•Tell me about your work.
Do you enjoy your work?
Your co-workers?
•What kind of stress do
you have?
•Who is the current
financial supporter?
•Do you current income
meet your needs?
 Stress Levels &
Coping Styles
•(what does the client
do to relieve stress &
find coping)
•Describe you stress
level. What makes you
angry?
•How do you manage
anger & stress?
•What is the greatest
stressor in you life?
•Where do you turn for
help during crisis?
Environment
(physical, chemical or
psychological
situation...risk to
client)
•What risk s…do you
participate?
•What precautions do
you take?
•Do you believe that
you are ever in danger
of becoming a victim
of violence?
 Developmental level
• Developmental delay: strong indicators
where the client is functioning much
below the usual behavior for his age-
point areas for nursing diagnoses &
intervention.
• Sometimes client skips one or more
developmental level, & at a later stage of
maturity then goes back & successfully
works through the missed levels.
Young Adult: Intimacy
vs. Isolation (18-25)
(ability to form close,
caring relationships
with friends of both
sexes & various ages;
having established
identity apart from
the childhood family…
otherwise…social &
emotional isolation
may occur…leading to
addiction, sexual
promiscuity)
Middle Adulthood:
Generativity vs.
Stagnation(25-45)
(able to share self
with others,
mentoring &
sharing to future
generations…
providing wisdom
& experience)
Middle Adulthood:
Generativity vs.
Stagnation
(Stagnation occurs when…
fails to accomplished one or
more previous developmental
tasks…is unable to give to
future generations…total
dependency on work, favorite
child, or even a pet…
incapable of giving to others…
unfinished schoolwork or
project…can’t let go & move
on…paralyzing stagnation…)
Older Adult:
Integrity vs.
Despair (45-65 &
above)
(looking back
finding life was
good…or
despairs that
goals were not
accomplished)