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College of Nursing
XAVIER UNIVERSITY
Ateneo de Cagayan
NCM 101 – Health Assessment LECTURE

Nursing Interview Guide to Collect Subjective Data from the Client

Questions Findings
Today’s Date February 12, 2022
Name of Interviewer Ira Velle J. Vios
Name of Interviewee Hannerly Achacoso
Biographical Data
Name Hannerly Luz Achacoso
Gender Female
Address Luto, Alihawan, Bohol
Phone number 09263833985
Date of Birth March 15, 2003
Place of Birth Tagbilaran Bohol
Nationality or Ethnicity Filipino
Marital Status Single
Religion Roman Catholic
Primary and secondary languages spoken, written Bisaya, Tagalog, English
and
read; birth language
Educational Level High School Graduate, Freshman
(currently)
Occupation and Working Status Student
Who lives with the client? Identify significant Roommate
others
Caregivers and support people for the client Parents, Tita (father side)
Reason for Seeking Health Care
1. What is your major health care or concern? Unusual symptoms: blurry vision; long
duration of healing
2. Are you comfortable with seeking care First time; recommended by someone she
from this organization/institution knows
(hospital, clinics,
health centers)? Past experiences
good or not?
History of Present Health Concern
(use COLDSPA when appropriate)
1. Character of symptom or condition Blurry and takes time to heal wounds even
small wounds takes time to heal frequent
urination at night
2. Onset (when did it begin; better? worse? Blurry vision: last month (same)
same?) Healing of wounds: 2 weeks ago (better
but still takes time to heal)
Frequent urination: a month ago
3. Location (where and does it radiate?) Eyes, right leg near the knee
4. Severity (on scale of 1 – 10?) Blurry vision: 6/10
Healing of wounds: 5/10
Frequent urination: 8/10
5. Pattern (what makes it better? worse?) Blurry vision: ika tulog, undang gamit
gadgets, rest ang eyes to make it better
(after 3 hours) (minutes)
Healing of wounds: cleans the wounds
regularly but still, it heals slow; no infection
Frequent urination
6. Associated factors (other associated Sleeps late, wakes up early
symptoms? Effect on leisure or exercise?) Irregular eating schedule
Past Health History
Problems at birth? None
Childhood illnesses? None
Immunizations to date? Flu vaccine (last month)
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Acute or chronic adult illnesses (physical, None

emotional,
mental)?
Surgeries? None
Pregnancies? Births? Miscarriages? Abortions? None
Accidents? Injuries? None
Prolonged pain or pain patterns? None
Medications? None
Allergies? None
Family Health History
Recall as many genetic relatives as possible Father side: Cancer
(parents, grandparents, siblings) with age, Mother side: Diabetes
longevity, chronic illnesses (i.e., heart disease,
stroke, diabetes, cancer,
arthritis, Alzheimer’s).
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Questions Finding
s
Review of Systems
Skin, Hair and Nails: Skin color, temperature, Skin and nails: Normal
condition, excessive sweating, rashes, lesions, Hair: prone to hair fall
balding,
dandruff, condition of nails
Head and Neck: Headache, swelling, stiffness of Last week experienced sore throat
neck, difficulty swallowing, sore throat, enlarged
lymph
nodes
Eyes: Vision, eye infections, redness, Eyes: Blurry
excessive tearing, halos around lights,
blurring, loss of side vision, moving black
spots/specks in visual fields,
flashing lights, double vision and eye pain
Ears: Hearing, ringing or buzzing, earaches, Normal
drainage
from ears, dizziness, exposure to loud noises
Mouth, Throat, Nose and Sinuses: Condition of Sore throat last week
teeth and gums; sore throats; mouth lesions;
hoarseness; rhinorrhea; nasal obstruction;
frequent colds; sneezing or itching of eyes, ears,
nose or throat; nose
bleeds; snoring
Thorax and Lungs: Difficulty breathing, wheezing, Normal
pain, shortness of breath during routine activity,
orthopnea, cough or sputum, hemoptysis,
respiratory
infections
Breasts and Regional Lymphatics: Lumps or Normal
discharge from nipples, dimpling or changes in
breast size,
swollen or tender lymph nodes in axilla
Heart and Neck Vessels: Last blood pressure, Normal; palpitations only occur when
ECG tracing or findings, chest pain or drinking coffee
pressure,
palpitations, edema
Peripheral Vascular: Swelling or edema of legs and Normal
feet; pain; cramping; sores on legs; color or
texture changes on the legs or feet
Abdomen: Indigestion, difficulty swallowing, Normal
nausea,
vomiting, abdominal pain, gas, jaundice, hernias
Male Genitalia: Excessive or painful urination, N/A
frequency or difficulty starting and maintaining
urinary stream, leaking of urine, blood noted in
urine, sexual problems, perineal lesions, penile
drainage, pain or swelling in scrotum, difficulty
achieving an erection and/or difficulty
ejaculating, exposure to
sexually transmitted infections
Female Genitalia: Sexual problems; sexually Irregular menstruation
transmitted diseases; voiding problems (e.g., Frequent small amounts of urination
dribbling, incontinence); reproductive data such
as age at menarche, menstruation (length and
regularity of cycle), pregnancies and type of or
problems with delivery, abortions, pelvic pain,
birth control, menopause (date or year of last
menstrual period)
and use of hormone replacement therapy
Anus, Rectum and Prostate: Bowel habits, pain Normal
with defecation, hemorrhoids, blood in stool,
constipation,
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Musculoskeletal: Swelling, redness, pain, None/normal

stiffness of joints, ability to perform activities of
daily living,
muscle strength
Neurologic: General mood, behavior, Stressed
depression, anger, concussions, headaches, loss
of strength, memory problems, strange
thoughts and/or actions,
difficulty learning
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Questions Finding
s
Lifestyle and Health Practices
Profile
Description of Typical Day • Wakes up early but sleeps late
“Please tell me what an average or typical day is
for • Eating schedule is not right
you. Start with awakening in the morning and
continue until bedtime.” • Sometimes brunch
Nutrition and Weight Management • More on meat less vegetables
• “What do you usually eat during a typical recently
day? Please tell me the kinds of foods you
prefer, how often you eat throughout the • Brunch
day and how much you eat.”
• “Do you eat out at restaurants frequently?” • Snacks depends on mood mostly
• “Do you eat only when hungry? Do you once a day in the afternoon
eat because of boredom, habit,
anxiety, • Restaurants
depression?”
• “Who buys and prepares the food you • Eats when hungry
eat?”
• “Where do you eat your meals?” • Water mostly, stopped drinking
• “Ho w much and what types of fluids do coffee
you drink?”
Activity Level and Only workouts when it is a requirement for
Exercise school
• “What is your daily pattern of activity?”
• “Do you follow a regular exercise plan?
What types of exercise do you do?”
• “Are there any reasons why you cannot
follow a moderately strenuous exercise
program?”
• “What do you do for leisure and
recreation?”
• “Do your leisure and recreational activities
include exercise?”
Sleep and Rest • Sleeps late, wakes up early
• “Tell me about your sleeping patterns.” (maximum of 6 hours)
• “Do you have trouble falling asleep or • Difficulty of sleeping
staying • Straight sleep if tired
asleep?” • Not a deep sleeper
• “How much sleep do you get each night?” • Closes eyes until she falls asleep
• “Do you feel rested when you awaken?” • Drinking milk helps
• “Do you nap during the day? How often
and for how long?”
• “What do you do to help you fall asleep?”
Substance Use • Drinks on occasions
• “How much beer, wine or other • Water stops drinking coffee
alcohol do you drink on the average?” • Not a smoker
• “Do you drink coffee or other • Paracetamol for fever
beverages containing caffeine (e.g., • Vitamin C
cola)? If so, how much and how
often?”
• “Do you now or have you ever smoked
cigarettes or used any other form of
nicotine? How long have you been
smoking/did you smoke? How many
packs per week? Tell me about any
efforts to quit.”
• “Have you ever taken any medication not
prescribed by your health care provider?
If so, when, what type, how much and
why?”
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• “Have you ever used, or do you now

use, recreational drugs? Describe any
usage.”
• “Do you take vitamins or herbal
supplements? If so, what?”
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Questions Finding
s
Self-Concept and Self-Care Responsibilities • Consider herself not having a
• “What do you see as your talents or talent
special abilities?”
• “How do you feel about yourself? About • Not insecure accepts self
your appearance?” • Doesn’t go outside because of
• “Can you tell me what activities you Covid
do to keep yourself safe, healthy or to
prevent disease?” • Dentist: every 3 months
• “Do you practice safe sex?”
• “How do you keep your home safe?”
• “Do you drive safely?”
• “How often do you have medical check-ups
or
screenings?”
• “How often do you see the dentist or
have your eyes (vision) examined?”
Social Activities • Watching movies
• “What do you do for fun and relaxation?”
• “With whom do you socialize most • Roommates
frequently?”
• “Are you involved in any
community activities?”
• “How do you feel about your community?”
• “Do you think that you have enough
time to socialize?”
• “What do you see as your
contribution to society?”
Relationships • Loved ones (family and boyfriend)
• “Who is (are) the most important person(s)
in • Family and boyfriend: healthy
your life?” relationship
• “Describe your relationship with that
person.”
• “What was it like growing up in your
family?”
• “What is your relationship like with
your spouse?”
• “What is your relationship like with
your children?”
• “Describe any relationships you have with
significant others.”
• “Do you get along with your in-laws?”
• “Are you close to your extended family?”
• “Do you have any pets?”
• “What is your role in your family? Is
it an important role?”
• “Are you satisfied with your current
sexual relationships? Have there been
any recent
changes?”
Values and Belief System • Studies
• “What is most important to you in life?” • To be a RN
• “What do you hope to accomplish in • Relationship with God is important
your life?” • God and loved ones give her hope
• “Do you have a religious affiliation? Is and strength
this important to you?”
• “Is a relationship with God (or another
higher
power) an important part of your life?”
• “What gives you strength and hope?”
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Questions Finding
s
Education and Work • School is okay but stressful
• “Tell me about your experiences in (pressure)
school or about your education.”
• “Are you satisfied with the level of • Satisfied
education you have? Do you have future
educational
plans?”
• “What can you tell me about your
work? What are your responsibilities
at work?”
• “Do you enjoy your work?”
• “How do you feel about your co-workers?”
• “What kind of stress do you have that is
work
related? Any major problems?”
• “Who is the main provider of financial
support in your family?”
• “Does your current income meet
your needs?”
Stress Levels and Coping Styles • She hates people always asking
• “What types of things make you angry?” questions
• “How would you describe your stress • 6/10: stress level
level?” • Movies help her cope up her stress
• “How do you manage anger or stress?” • Mostly self helps her during crisis
• “What do you see as the greatest
stressors in your life?”
• “Where do you usually turn for help in a
time of crisis?”
Environment • Theft
• “What risks are you aware of in
your environment such as in your • Doesn’t know many people in her
home, neighborhood, on the job, or current environment
any other activities in which you
participate?” • Reading the directions first
• “What types of precautions do you take,
if any, when playing contact sports, using
harsh chemicals or paint, or operating
machinery?”
• “Do you believe you are ever in danger of
becoming a victim of violence? Explain.”

* Adopted from Laboratory Manual for Health Assessment in Nursing, 5th ed., Kelly, J. and Weber, J.
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Learning Feedback Diary

For this activity I have learned that the collection of subjective data from the
client is very important. Following the correct sequence of the data collection
can avoid confusion and can make the assessment faster and understandable.
The gathering of vital and pertinent information concerning the symptoms
and their consequences on the patient's health might provide the attending
C physician with further information about the patient's medical history. It gives
(Context) a comprehensive picture of a patient's health care history and current health
behaviors. Identifying allergies and family health history is also important,
since they may have a significant influence on a person's well-being and can be
readily adjusted. Determine whether a patient is at risk for a genetic or family
illness, as well as suggest areas for health promotion and sickness prevention.
Because it is easier for the doctor to weigh things out, the patient recovers
faster.
For this activity, I had a fun experience despite the connectivity issue that my
interviewee was experiencing it was not a hassle to navigate through the
document and I did not find it hard to catch up. The document was well made,
a very organize one, specific, it helps the duration of the interview faster, but
E the important data was still gathered. The PLP’s was a huge help as well, the
(Experience) PLP’s given were already summarized and it was not that hard to understand.
There were also acronym’s given that helped me a lot in the data collection.
This activity taught me to become more patient and polite to the people around
me, it taught to how to become attentive and considerate of others.
I mentioned in the experience part that this activity taught me a lot of things. It
This activity taught me to become more patient and polite to the people around
me, it taught to how to become attentive and considerate of others. Being a
nurse requires a great amount of patience indeed, nurses encounter different
R patients every day, different health problems, different attitudes, different
(Reflection) religion, etc. It is important to always follow these data collection objectively
and not miss a single thing because if you miss one question it can greatly
contribute to the results, things might not go so well, and findings may not be
that reasonable.
As an aspiring nursing student, it is important for me to take these lessons to
heart, it is because I am handling life and a lot of patients may depend on me in
the future. I must study hard and practice every activity seriously, read PLP’s,
A
watch recorded sessions and participate in class actively. I should also take my
(Action) return demonstrations to heart and engrave it in my mind for it is a huge help in
my career in the future.
Overall, I think I did great for this activity. I did not miss any question and I
treated my partner like my real patient. Though the interaction was online, and
there were communication barriers, I still managed to assess my partner, did
E not miss any question, and learned so much from the activity; and that is for
(Evaluation) me the most important part – learning. I will put to heart all of the things I’ve
learned here and focus more in my studies for this will surely help me.

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