Health Assessment in Nursing 04/09/2021

Thorax 2
Philippe John Federico

Activity E. INTERVIEWING AND RECORDING ASSESSMENT FINDINGS

Nursing Interview Guide to Collect Subjective Data from the Client

Questions Findings
Current Symptoms
1. Difficulty breathing (at rest, with Shortness of breath when performing in
specific activities while sleeping, other extreme activities, but normal breathing rate
symptoms when having trouble while resting and sleeping. Shortness of
breathing)? breath can also occur as a result of drinking
too much coffee, as caffeine causes shallow
breathing.
2. Chest pain associated with a cold, So far, none, because the chest pain,
fever, or deep breathing? recently, which I normally feel is due to
exhaustion.
3. Cough with or without sputum? I recently had a dry cough but it did not
produce phlegm or sputum.
Past History
1. Prior respiratory problems None.
2. Previous thoracic surgery, biopsy, or None.
trauma?
3. Allergies, symptoms/treatments? Allergic with Seafoods. When it happens, I
get red spots on my nape of the neck, and
the medication I used to take was
antihistamines.
4. Pulmonary studies/tests: chest x-ray, Been x-rayed a couple of months ago but
TB skin test, or influenza results are normal.
immunization?
Family History
1. Family history of lung disease? None
Lifestyle and Health Practices
1. Use of tobacco products, cigarettes or No
cigars (number of years, number per
day)?
2. Exposure to environmental conditions Yes
that affect breathing at work or at
home, including secondhand smoke?
3. Difficulty performing usual daily Not all the time.
 activities?
4. Degree of stress, effect on breathing? Mild to moderate.
5. Medications for breathing (prescribed Water therapy.
or OTC), other breathing treatments?