NCMA111: HEALTH ASSESSMENT PRELIMS

02
Prof. Vinz Acena, MAN, RN, RM / Second Semester
Transcriber: Kathleen Venus 23

SUBJECTIVE DATA COLLECTION

WORKING PHASE
OUTLINE
- Longest Phase
I. DATA
- Verbal / Nonverbal
A. PHASES OF INTERVIEW
- The nurse elicits the client’s comments about
B. FACTORS TO CONSIDER DURING INTERVIEW
major biographic data, reasons for seeking
C. THINGS TO AVOID DURING AN INTERVIEW
care, history of present health concern, past
II. COLLECTION OF SUBJECTIVE DATA THROUGH
health history, family history, review of body
INTERVIEW AND HEALTH HISTORY
systems for current health problems, lifestyle
III. GLASGOW COMA SCALE
and health practices, and developmental level
IV. LEVELS OF CONSCIOUSNESS
- The nurse listens, observes cues, and uses
critical thinking skills to interpret and validate
DATA information received from the client
TYPES OF DATA - The nurse and client collaborate to identify the
a. Subjective Data client’s problems and goals
- symptoms SUMMARY AND CLOSING PHASE
- apparent only to the person affected - Summarize / Restate
b. Objective Data - Clarify
- signs - The nurse summarizes information obtained
- detectable by an observer during the working phase and validates
- can be measured, tested problems and goals with the client
SOURCES OF DATA - The nurse identifies and discusses possible
a. Client plans to resolve the problem (nursing
- best source of data, subjective data diagnoses and collaborative problems) with the
b. Support People/Significant Other client
- family members, friends and caregivers - Finally, the nurse makes sure to ask if anything
- Important source of data if the client is young, else concerns the client and if there are any
unconscious or confused further questions
c. Client Records
- Information documented by other healthcare FACTORS TO CONSIDER DURING INTERVIEW
professionals TIME
d. Health Care Professionals - When the client is physically comfortable and
- Verbal reports free of pain
e. Literature PLACE
- journals, reference texts, published studies - Well – lighted, well – ventilated room, free of
DATA COLLECTION METHODS noise and distractions
a. Observing SEATING ARRANGEMENT
- To gather data using the senses - Ideal seating arrangement: the nurse and
- A conscious, deliberate skill patient sit in two chairs placed at right angle to
Two aspects of observing: a desk or a table or a few feet apart with no
o Noticing the data table
o Selecting, organizing and interpreting DISTANCE
the data - Maintain a 2 to 3 feet distance during interview
b. Interview LANGUAGE
- Planned communication or conversation with a - Avoid medical jargon
purpose - Translators, interpreters
- To get or give information ACTIVITIES OF DAILY LIVING (ADL)
- Identify problems of mutual concern HYGIENE
- Evaluate change, teach, provide support - bathing, grooming, shaving and oral care
- Provide counselling or therapy CONTINENCE
DRESSING
PHASES OF INTERVIEW EATING
PRE-INTRODUCTORY PHASE - the ability to feed oneself
- Nurse reviews the medical record before TOILETING
meeting with the client - the ability to use a restroom
- If a medical record is not established, the nurse TRANSFERRING
will need to rely on interview skills to elicit valid - actions such as going from a seated to
and reliable data from the client and that standing position and getting in and out of bed
individual’s family or significant other
INTRODUCTORY PHASE THINGS TO AVOID DURING AN INTERVIEW
- The nurse explains the purpose of the - Biasing yourself
interview, discusses the types of questions that - Letting family members answer for patient
will be asked, explains the reason for taking - Asking more than one question at a time
notes, and assures the client that confidential - Not allowing enough response time
information will remain confidential - Using medical jargon
- The nurse should develop trust and rapport at - Assuming rather than clarifying and validating
Page1

this point in the interview - Offering false reassurance

[NCMA111] 2.00 SUBJECTIVE DATA COLLECTION – Mr. Francis Vincent Acena
COLLECTION OF SUBJECTIVE DATA THROUGH o Are there any treatments you’ve tried
INTERVIEW AND HEALTH HISTORY that relieve the pain?”
- Associated Factors
A. BIOGRAPHICAL DATA
o What other symptoms do you have
- Usually include information that identifies the
with it?
client, such as name, address, phone number,
o Will you be able to continue doing
gender, and who provided the information—the
your work or other activities (leisure or
client or significant others
exercise)?
B. REASONS FOR SEEKING HEATH CARE
o What other symptoms occur with it?
- Reason for seeking health care (major health
How does it affect you?
problem or concern)
o “What do you think caused it to start?
- Feelings about seeking health care (fears and
o Do you have any other problems that
past experiences)
seem related to your back pain? How
This category includes two questions:
does this pain affect your life and daily
o “What is your major health problem or
activities?”
concerns at this time?”
b. PAST HEALTH HISTORY
▪ This question assists the
- Ask about:
client in focusing on the most
o Childhood illness
significant health concern
o Childhood immunizations
and answers the nurse’s
o Adult illnesses
question, “Why are you
o Past surgeries or accidents
here?” or “How can I help
o Experienced pain
you?”
o Allergies
▪ Physicians call this the
o Hospitalizations
client’s chief complaint (CC)
o Pregnancies
o “How do you feel about having to seek
o Births
health care?”
o Injuries
▪ This question encourages
o Medications
the client to discuss fears or
o Emotional or psychiatric problems
other feelings about having
- Sample questions:
to see a health care provider.
o “What diseases did you have as a
▪ This question may also draw
child?”
out descriptions of previous
o “What immunizations did you get and
experiences—both positive
are you up to date now?”
and negative—with other
o “Do you have any chronic illnesses? If
health care providers.
so, when were they diagnosed? How
C. HISTORY
are they treated? How satisfied have
a. HISTORY OF PRESENT ILLNESS (using
you been with the treatment?”
COLDSPA to explore signs &
o “What illnesses or allergies did you
symptoms)
have? How were the illnesses
- Character
treated?”
o Describe the sign or symptom (feeling,
D. FAMILY HISTORY
appearance, sound, smell, or taste if
E. CURRENT MEDICATIONS
applicable)
- Sample questions:
o “What does the pain feel like?”
o “What medications have you used in
o How does it feel, look, smell, sound,
the recent past and currently, both
etc.?
those that your doctor prescribed and
- Onset
those you can buy over the counter at
o When did it begin; is it better, worse,
a drug or grocery store? For what
or the same since it began?
purpose did you take the medication?
o “When did this pain start?”
How much (dose) and how often did
- Location
you take the medication? Do you take
o Where is it? Does it radiate?
any medications not prescribed for
o Does it occur anywhere else?
you but prescribed for a family
o “Where does it hurt the most?
member/friend or purchased on the
o Does it radiate or go to any other part
street?”
of your body?
F. LIFESTYLE AND HEALTH PRACTICES PROFILE
- Duration
- A very important section of the health history
o How long does it last? Does it recur?
because it deals with the client’s human
o “How long does the pain last?
responses, which include:
o Does it come and go or is it constant?”
Description of typical day
- Severity
- Elicit an overview of how the client sees his
o How bad is it on a scale of 1 (barely
usual pattern of daily activity
noticeable) to 10 (worst pain ever
- Encourage the client to discuss a usual day,
experienced)?
which, for most people, includes work or school
o How much does it bother you?
Nutritional and weight management
o “How intense is the pain? Rate it on a
- These questions uncover food habits that are
scale of 1 to 10.
health promoting as well as those that are less
- Pattern
desirable.
o What makes it better? What makes it
- Ask the client to:
worse?
o Recall what consists of an average
o “What makes your back pain worse or
24-hour intake with emphasis on what
Page2

better?
foods are eaten and in what amounts
[NCMA111] 2.00 SUBJECTIVE DATA COLLECTION – Mr. Francis Vincent Acena
o What snacks, fluid intake, and other -Helps to determine the client’s current level of
substances they consumed social development
- Sample questions: - Sample questions:
o “What do you usually eat during a o “What do you do for fun and
typical day? Please tell me the kinds relaxation?”
of foods you prefer, how often you eat o “With whom do you socialize most
throughout the day, and how much frequently?”
you eat?” o “Are you involved in any community
o “Do you eat out at restaurants activities?
frequently? VALUES AND BELIEF SYSTEM
ACTIVITY AND EXERCISE PATTERNS - Assess the client values, and discuss the
- Assess how active the client is during an clients’ philosophical, religious, and spiritual
average week either at work or at home beliefs
- Distinguish between activity done when - Some clients may not be comfortable
working, which may be stressful and fatiguing, discussing values or beliefs, feelings should be
and exercise, which is designed to reduce respected
stress and strengthen the individual - The data can help to identify important
- Explain to the client that regular exercise problems or strengths
reduces the risk of heart disease, strengthens - Sample questions:
heart and lungs, reduces stress, and manages o “What is most important to you in life?”
weight GLASGOW COMA SCALE
- Sample questions: FEATURE RESPONSE SCORE
o “What is your daily pattern of activity?” Open
o “Do you follow a regular exercise 4
spontaneously
plan? What types of exercise do you Best eye Open to verbal
3
do?” response command
o “Are there any reasons why you Open to pain 2
cannot follow a moderately strenuous No eye opening 1
exercise program?” Oriented 5
SLEEP AND REST PATTERNS Confused 4
- Questions should focus on specific sleeping Best verbal Inappropriate words 3
response Incomprehensible
patterns such as how many hours a night the 2
words
person sleeps, interruptions, whether the client No verbal response 1
feels rested, problems sleeping (e.g., Obeys command 6
insomnia), rituals the client uses to promote Localizing pain 5
sleep, and concerns the client may have Withdrawal from
regarding sleep habits Best motor 4
pain
response
- Sleep requirements vary depending on age, Flexion to pain 3
health, and stress levels Extension to pain 2
- Sample questions: No motor response 1
o “Tell me about your sleeping
patterns.” LEVELS OF CONSCIOUSNESS
o “Do you have trouble falling asleep or Pt responds appropriately
staying asleep?” Alert to stimuli; can open eyes,
o “How much sleep do you get each look at examiner
night? Pt appears drowsy; can
SUBSTANCE USE open eyes, look at
- Information provides the nurse with information Lethargy examiner, respond to
concerning lifestyle and a client’s self-care questions, but pt falls
ability asleep easily
- Use of substance can affect the client’s health Pt can open eyes, look at
and cause loss of function or impaired senses examiner, but responds
- Sample questions Obtunded slowly and is confused;
o “How much beer, wine, or other decreased alertness and
alcohol do you drink on average?” interest in environment
o “Do you drink coffee or other Pt can be aroused from
beverages containing caffeine (e.g., sleep only with painful
cola)?” If so, how much and how stimuli; verbal responses
often? are slow or absent; returns
SELF-CARE ACTIVITIES Stupor
to unresponsive state when
- basic hygiene practices stimuli removed; minimal
- regularity of health care checkups (i.e., dental, awareness of self or
- visual, medical) breast/testicular self- environment
examination unconscious state, pt
- accident prevention cannot be aroused, eyes
- hazard protection (e.g., seat belts, smoke Coma
remain closed, no response
alarms, and sunscreen) to external stimuli
SOCIAL AND COMMUNITY ACTIVITIES
- Help the nurse to discover what outlets the
client has for support and relaxation and if the
client is involved in the community beyond
family and work
Page3