NCM 101-HEALTH

ASSESSMENT
SKILLS LAB

WEEK 2
INTERVIEW AND
HEALTH HISTORY
TAKING

PRELIM PERIOD
 Introduction:
► Establishing rapport and a trusting relationship
with the client are important factors to consider in
order to elicit accurate and meaningful information.

► Interview is an important step in health

assessment of the patient. If interview and health
history taking are done effectively, doctors, nurses
and other members of the healthcare team can
design an anticipatory guidance for patient’s care.
STEPS OF HEALTH ASSESSMENT
A. Collecting Subjective Data

> sensations or symptoms: pain, hunger, dizziness,

feelings: happiness, sadness
>Perceptions, desires, preferences, beliefs, ideas, values and
personal information
Source: patient himself

Major Areas of Subjective data:

⮚ Biographical information: name, age, religion, address, birthday,
birthplace, occupation
⮚ Physical symptoms related to each body parts
⮚ Past health history
⮚ Family history
⮚ Health and lifestyle practices that put the client at risk: nutrition,
activity
Method Used: Interview
INTERVIEWING:
⮚ Vital for accurate collection of subjective data
⮚ Requires professional, interpersonal and
interviewing skills

Purposes/Focus:
1.Establishing rapport and a trusting relationship with
the client to elicit accurate and meaningful
information
2.Gathering information on the client’s
developmental, psychological, physiologic,
sociocultural and spiritual statuses, to identify
deviations that can be treated with nursing and
collaborative interventions or strengths that can be
enhanced through nurse – client collaboration.
Method Used: Interview
INTERVIEWING:
⮚ Vital for accurate collection of subjective data
⮚ Requires professional, interpersonal and
interviewing skills

Purposes/Focus:
1.Establishing rapport and a trusting relationship with
the client to elicit accurate and meaningful
information
2.Gathering information on the client’s
developmental, psychological, physiologic,
sociocultural and spiritual statuses, to identify
deviations that can be treated with nursing and
collaborative interventions or strengths that can be
enhanced through nurse – client collaboration.
PHASES OF THE INTERVIEW
PREINTRODUCTORY PHASE
⮚ The nurse reviews the medical record before
meeting with the client
1.INTRODUCTORY PHASE
> Introducing one’s self to the client and relative as
well
>Explains the purpose of the interview
>Discusses the types of questions that will be asked
>Explains the reason for taking notes
>Assures confidentiality
>Makes the client comfortable
>Maintains client’s privacy
PHASES OF THE INTERVIEW
PREINTRODUCTORY PHASE
2. WORKING PHASE
> The nurse elicits the client’s comments about
major biographic data
>Reasons for seeking care
>History of present and past health history, family
history, review of body systems for current health
problems, lifestyle and health practices and
developmental level.
>The nurse listens, observes cues and uses
critical thinking skills to interpret and validate
information received from the client
PHASES OF THE INTERVIEW
PREINTRODUCTORY PHASE
3. WORKING PHASE
>The nurse and client collaborates to identify the
client’s problems and goals.

4. SUMMARY AND CLOSING PHASE

>The nurse summarizes information obtained
during the working phase
>Validates problems and goals with the client
>Discusses possible plans to resolve the problem
with the client
COMMUNICATION DURING THE INTERVIEW:
TWO TYPES OF COMMUNICATION
1. NON VERBAL COMMUNICATIONS

a. Appearance
> wear comfortable, neat clothes, a laboratory coat or
uniform, id, name tag with credentials, hair should be
neat, fingernails should be short and neat; jewelry
should be minimal
b. Demeanor
⮚ avoid laughing, or yelling at other co-workers,

⮚ poise of a professional, greet the client calmly, avoid

being overly friendly and touchy; maintain a

professional distance
NON VERBAL COMMUNICATIONS

c. Facial expression - keep your expression

neutral and friendly
d. Attitude: non judgmental attitude
e. Silence: periods of silence allows you and the
clients to organize thoughts
f. Listening: maintain good eye contact, smile or
display an open, appropriate facial expressions,
maintain an open body position (open arms and
hands and lean forward)
2. VERBAL COMMUNICATION

a.Open ended questions-to elicit client’s feelings and perceptions, begin with
the words “how” or “what”

b.Closed – ended questions- used to focus on specific information, client

can respond with one or two words, use the words “when” or “did” Example:
when did your headache start?

c. Laundry List – provide the client with the list of feelings to choose from in
describing symptoms, conditions, or feelings
d. Rephrasing – helps the nurse to clarify information the client has stated, it
also enables the nurse and the client to reflect on what was said
e. Well placed phrases – listen closely to the client during her or his description
and use phrases such as “ um-hum” “yes” or “I agree” to encourage the client to
continue
f. Inferring- if used properly helps to elicit the most accurate data possible from
the client
►
REVIEW OF SYSTEMS FOR CURRENT
HEALTH PROBLEMS

⮚ Include only the client’s subjective information

⮚ Document the client’s own description of her health
status for each body systems
⮚ Used words that the client understands
⮚ Lifestyle and health Practices Profile
⮚ How the client manages her life, the support they have
⮚ Nutrition and weight management
⮚ Activity level and exercise
⮚ Sleep and rest
REVIEW OF SYSTEMS FOR CURRENT
HEALTH PROBLEMS

⮚ Medication and substance use

⮚ Self care and self responsibilities
⮚ Social activities
⮚ Relationships
⮚ Values and belief system
⮚ Education and work
⮚ Stress level and coping styles
⮚ Environment
Write Up: Health
History
GENERAL SURVEY
Goal:

► The assessment is completed without the patient experiencing anxiety or

discomfort, an overall impression of the patient is formulated, the findings
are documented, and the appropriate referral is made to other healthcare
professionals, as needed for further evaluation.
Procedure

► Perform hand
hygiene and put on
PPE, if indicated.
► Identify the patient.
► Close curtains around bed and the door to the room, if
possible.
► Explain the purpose of the health examination and what
you are going to do. Answer any questions.
► Assess the patient’s physical appearance.
► Observe if the patient appears his or her stated age.
► Note the patient’s mental status.
► Is the person alert and oriented, responsive to questions and responding
appropriately? Are the facial features symmetric?
► Note any signs of acute distress, such as shortness of breath, pain, or
anxiousness.
► Assess the patient’s body structure.
► Does the person’s height appear within normal range for stated age and
genetic heritage?
► Does the person’s weight appear within normal range for height and body
build?
► Note if body fat is evenly distributed.
► Do body parts appear equal bilaterally and relatively proportionate? Is the
patient’s posture erect and appropriate for age?
► Assess the patient’s mobility. Is the patient’s gait smooth, even, well-
balanced, and coordinated?
► Is joint mobility smooth and coordinated with a general full range of motion
(ROM)? Are involuntary movements evident?
► Assess the patient’s behavior.
► Are facial expressions appropriate for the situation?
► Does the patient maintain eye contact, based on cultural norms?
► Does the person appear comfortable and relaxed with you?
► Is the patient’s speech clear and understandable?
► Observe the person’s hygiene and grooming.
► Is the clothing appropriate for climate, fit well, appear clean, and
appropriate for the person’s culture and age group?
► Does the person appear clean and well groomed, appropriate for age and
culture?
► Assess for pain.
► Have the patient remove shoes and heavy outer clothing. Weigh the patient using
a scale. Compare the measurement with previous weight measurements and
recommended range for height.
► With shoes off, and standing erect, measure the patient’s height using a wall-
mounted measuring device or measuring pole. Compare height and weight with
recommended average weights on a standardized chart.
► With shoes off, and standing erect, measure the patient’s height using a wall-
mounted measuring device or measuring pole. Compare height and weight with
recommended average weights on a standardized chart.
► Using the tape measure, measure the patient’s
waist circumference. Place the tape measure
snugly around the patient’s waist at the level of
the umbilicus.
► Measure the patient’s temperature, pulse, respirations, blood pressure, and
oxygen saturation.
► Remove PPE, if used. Perform hand hygiene.
► Continue with assessments of specific body systems as appropriate or
indicated. Initiate appropriate referral to other healthcare practitioners for
further evaluation as indicated.
References

► Udan, J. (2021) Health Assessment and Physical Examination 2nd Edition