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Chapter 5 Practical and Vocational Nurses and the Nursing Process 59

BOX 5-3

COMPONENTS OF A NURSING HEALTH HISTORY

Biographic Data Family History of Illness

Client’s name, address, age, sex, marital status, occupation, religious ■ Heart disease, cancer, genetic abnormality
preference, health care financing, and usual source of medical care
Lifestyle
Chief Complaint or Reason for Visit ■ Personal habits: tobacco, alcohol, coffee, etc.
The answer given to the question “Why did you come here today?”
■ Diet
■ Sleep/rest patterns
History of Present Illness
■ Activities of daily living (ADLs): any difficulties in performing
■ Provocation or palliation: what causes it, what relieves it the basic activities
■ Quality and quantity: type of pain and intensity ■ Recreation/hobbies
■ Region or radiation: where it is, where it goes
■ Scale of pain: 1 to 10 Social Data
■ Timing: when it began, how long it lasts, and how often it ■ Client’s support system: family, friends, professional counseling
occurs ■ Ethnic affiliation
■ Highest level of education
Past History ■ Occupation and employment: Has illness affected ability to work?
■ Childhood illnesses ■ Health insurance
■ Childhood immunizations ■ Home and neighborhood conditions (if applicable)
■ Allergies
■ Accidents and injuries Psychologic Data
■ Hospitalization for serious illnesses ■ Major stressors
■ Medication: all currently used prescription and over-the-counter ■ Usual coping pattern
medication, such as aspirin, nasal spray, vitamins, or laxatives ■ Communication style

client data observed through four of the five senses are
shown in Table 5-1 ■.
Observation involves interpretation of data. The LPN/
LVN and the RN work together (collaborate) to determine
the meaning of the observation.
BOX 5-4
Interviewing
An interview is a planned communication or a conversation
with a purpose. When nurses interview clients, they ask ques-
tions, help identify client problems, and give information. For
example, a client who is a newly diagnosed diabetic may be
interviewed by the nurse to determine the level of knowledge
about the disease, areas that need more teaching, and how well

EXAMPLES OF SUBJECTIVE AND TABLE 5-1

OBJECTIVE DATA
Use of the Senses in Collecting Data
Subjective
SENSES EXAMPLE OF CLIENT DATA
■ “I feel weak all over when I try to walk down the hall.”
■ Client states he has a cramping pain in his abdomen. States, Vision Overall appearance (body size, general weight,
“I feel sick to my stomach.” posture, grooming); signs of distress or discomfort;
■ “I’m short of breath.” facial and body gestures; skin color and lesions;
■ Wife says, “He doesn’t seem so sad today.” abnormalities of movement; nonverbal demeanor
■ “I would like to see the chaplain before surgery.” (e.g., signs of anger or anxiety); religious or cultural
artifacts (e.g., books, icons, candles, beads)
Objective
■
Smell Body or breath odors
Blood pressure 90/50
■ Apical pulse 104 Hearing Breath and heart sounds; bowel sounds; ability to
■ Skin pale and diaphoretic communicate; language spoken; ability to initiate
■ Vomited 100 mL green-tinged fluid conversation; ability to respond when spoken to;
■ Abdomen firm and slightly distended orientation to time, person, and place; thoughts and
■ Active bowel sounds auscultated in all four quadrants feelings about self, others, and health status
■ Lung sounds clear bilaterally; diminished in right lower lobe
■ Cried during interview Touch Skin temperature and moisture; muscle strength
■ Holding open Bible (e.g., hand grip); pulse rate, rhythm, and volume; pal-
■ Has small silver cross on bedside table patory lesions (e.g., lumps, masses, nodules)