Module 2: Steps of Health Assessment:

Collection of Subjective Data Through Interview and Health Assessment

Learning Outcomes: Upon completion of this module, students will be expected to:
1. Assess one’s/ peer health status/ competence utilizing correct
assessment techniques.
2. Integrate evidence-based practice in conducting health assessment.
3. Manage resources (human, physical and time) efficiently and
effectively in health assessment.
4. Maintain a safe environment in conducting health assessment.
5. Document health assessment data properly.
6. Ensure accuracy, completeness, and integrity of health assessment
data.
7. Adhere to guidelines in documentation related to confidentiality of
health assessment data.
8. Use appropriate technology in performing health assessment.
9. Apply systems informatics in health assessment.
10. Customize health assessment process based on the culture and values
of the client/family.
Reference:

Introduction
There are four steps in health assessment, and they might overlap or you might perform
two or three steps concurrently. Before actually meeting the client and beginning the nursing
health assessment, there several things you should do to prepare. It is helpful to review the
client’s record, if it is available. Knowing the client’s basic biographical data (age, sex, religion and
occupation is helpful. It provides background about chronic diseases and gives clues to how a
present illness may impact the client’s activities of daily living. Also useful in documented
information regarding the client’s medical diagnoses and progress notes. These give you an
opportunity to verify what you read with what the client tells you and to ask further questions as
needed. Remember also to obtain and organize materials that you will need for the assessment.
The materials may be assessment tools that will guide you in collection of data and equipment
that are necessary to perform nursing health assessment.
Subjective data are sensation or symptoms (e.g. pain, hunger), feelings (e.g. happiness,
sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that
can be elicited and verified only by the client. To elicit accurate subjective data, learn to use
effective interviewing skills with a variety of clients in different settings. The major areas of
subjective data includes:
✓ Biographical information (name, age, religion, occupation)
✓ Physical symptoms related to each body part or system (e.g. eye and ears,
abdomen)
 ✓ Past health history
✓ Family history
✓ Health and lifestyle practices (e.g. health practices that put the client at risk,
nutrition, activity, relationship, cultural beliefs or practices, family structure and
function, community environment).
✓ Review of systems

❖ Interviewing
Obtaining a valid nursing health history requires professional, interpersonal,
interviewing skills. The nursing interview is a communication process that has two
focuses:
▪ Establishing rapport and trusting relationship with the client to elicit accurate and
meaningful information.
▪ Gathering information on the client’s developmental, psychological, physiologic,
sociocultural, spiritual status to identify deviations that can be treated with
nursing and collaborative interventions or strengths that can be enhanced
through nurse-client collaboration.

▪ Phases of Interview
The nursing interview has four basic phases:
1. Preintroductory Phase – the nurse review the medical record before meeting
with the client.
2. Introductory Phase – after introducing herself to the client, the nurse explains
the purpose of the interview, discusses the types of questions that will be asked,
explains the reason for taking notes and assures the client that confidential
information will remain confidential. The nurse makes sure that the client is
comfortable (physically and emotionally) and has privacy. Conducting the
interview at eye level with the client demonstrates respect and places the nurse
and client at equal levels. At this point in the interview, it is also essential for
nurses to develop trust and rapport, which is essential to promote full disclosure
of information. Developing rapport depends heavily on verbal and non-verbal
communication on the part of the nurse.
3. Working Phase – during this phase, the nurse elicits the client’s comments about
major biographical data, reasons for seeking care, history of present health
concern, past health history, family history, review of body system for current
health problem and health practices, and developmental level. The nurse then
listens, observes cues, and uses critical thinking skills to interpret and validate
information received from the client. The nurse and client collaborate to identify
the client’s problems and goals. The facilitating approach maybe free-flowing or
more structured with specific questions, depending on the time available and
the type of data needed.
 4. Summary and Closing Phase – the nurse summarizes the information obtained
during the working phase and validates the problem, and goals with the client.
She also identifies and discusses possible plans to resolve the problem with the
client. She makes sure that if anything else concerns the client and if there are
any further questions.

❖ Communication During Interview

▪ The client interview involves two types of communication:
1. Verbal
2. Nonverbal
▪ Nonverbal communication
➢ Is as important as verbal communication. Your appearance, demeanor,
facial expressions and attitude strongly influence how the client perceives
the questions you ask. Facilitate eye level contact. Never overlook the
importance of communication or take it for granted.
✓ Appearance – the nurse needs to make sure that they appear
professional. Wear comfortable, neat clothes and a laboratory coat or
a uniform. Be sure that your nametag is clearly visible. Your hair
should be neat and pulled back if long. Fingernails should be short and
neat; jewelry should be minimal.
✓ Demeanor – your demeanor should also be professional. When you
enter a room to interview a client, display poise. Focus on the client
and upcoming interview and assessment. Do not enter the room
laughing loudly, yelling to a coworker, or muttering under your
breathe. Greet the client calmly, by name and not with references
such as honey, sweetie, or sugar. Focus your full attention on the
client.
✓ Facial Expression – are often an overlooked aspect of communication.
Often shows what you are truly thinking. Keep your expression neutral
and friendly. If your face shows anger or anxiety, the client will sense
it sense it and may think it is directed toward him or her. Displaying a
neutral expression does not mean that your face lacks expression. It
means using the right expression at the right time. If the client looks
upset, you should appear and be understanding and concerned.
✓ Attitude – one of the most important nonverbal skills to develop as a
health care professional is a nonjudgemental attitude. All clients
should be accepted, regardless of beliefs, ethnicity, lifestyles and
health care practices. Do not act as though you feel superior to the
client or appear shocked.
✓ Silence – periods of silence allow you and the client to reflect and
organize thoughts, which facilitate more accurate reporting and data
collection.
✓ Listening – is the most important skill to learn and develop fully in
order to collect complete and valid data from your client. To listen
 effectively, you need to maintain good eye contact, smile or display
an open, appropriate facial expression, and maintain an open body
position (open arms and hands, and lean forward).
▪ Verbal communication
➢ Effective verbal communication is essential to a client interview. The goal
of the interview process is to elicit as much data about the client’s health
status as possible. There are several types of questions and techniques to
use during interview:
✓ Open-Ended Questions – are used to elicit client’s feeling and
perceptions. They typically begin with the words “how” or “what”.
These type of questions are important because they require more
than a “one-word: response from the client.
▪ Example: “How have you been feeling lately?”
✓ Closed-Ended Questions – are used to obtain facts and focus on
specific information. The client can respond with one or two words.
Closed-ended questions typically begin with the words “when” or
“did”.
▪ Example: “When did your headache start?
Laundry List – another way to ask question is to provide the client with
a list of words to choose from in describing symptoms, conditions, or
feelings.
▪ Example: “Is the pain severe, dull, sharp, mild, cutting or
piercing?”
“Does the pain occur once every year, day, month or
hour?”.
Rephrasing – this technique helps to clarify information the client has
stated; it also enables you and the client to reflect on what was said.
▪ Example: Your client, Mr. G., tells you that he has been really
tired and nauseated for 2 months and that he is scared because
he fears that he has some horrible disease. You might rephrase
the information by saying:
“You are thinking that you have a serious illness?”
Well-Placed Phrases – the nurse can encourage client verbalization by
using well-placed phrases.
▪ Example: “uh-huh”, “yes”, “I agree”
Inferring – may elicit more data or verify existing data. Be careful not
to mead the client to answers that are not true.
▪ Example: Your client, Mrs. J., tells you that she has bad pain.
You ask where the pain is, and she says, “My stomach.” You
noticed that the client has a hand on the right side of her lower
abdomen and seems to favor the entire right side. You say, “ It
seems you have more difficulty with the right side of your
 stomach.” (use the word “stomach” because that is the term the
client used).
Providing Information – provide the client with information as
question and concerns arise. Make sure you answer every question as
thoroughly as you can. If you do not know the answer, explain that
you will find out.
❖ Communication to Avoid
- In communicating with the client there are several things that you need to
avoid:
▪ Non-verbal Communication to Avoid
Excessive or Insufficient Eye Contact – avoid extremes in eye contact.
Some clients feel very uncomfortable with too much eye contact;
others believe that you are hiding something from them if you do not
look them in the eye. It is best to use a moderate amount of eye
contact.
▪ Example – Establish eye contact when the client is speaking to
you but look down at your notes from time to time.
Distraction and Distance – Avoid being occupied with something else
while you are asking question during an interview. This behavior
makes the client believe that the interview may not be important to
you. Avoid appearing mentally distant as well. Try to avoid physical
distance exceeding 2-3 feet during interview. Rapport and trust are
established when clients sense that your focus and concern are solely
on them and their health.
Standing – Avoid standing while the client is seated during an
interview. Standing puts you and the client on different level. You may
be perceived as the superior, making the client feel inferior. Care of
the client’s health should be an equal partnership. Vital information
may not be revealed if the client believes that the interviewer is
untrustworthy, judgmental, or disinterested.
▪ Verbal Communication to Avoid
Biased or Leading Questions – These cause the client to provide
answers that may not be true. The way you phrase a question might
actually lead the client to think that you want her/him to answer a
certain way.
▪ Example: If you ask, “You don’t feel bad, do you?”, the client
may conclude that you do not think that she should feel bad and
will answer “no” even if that is not true.
Rushing to the interview – If you ask questions on top of questions,
several things may occur. A client will usually sense that you are
rushed and may try to help hurry the interview by providing
abbreviated or incomplete answers to questions.
 ▪ Example: The client might answer “no” to a series of closed-
ended questions when she could have answered “yes” to one of
the questions if it were asked individually.
Rushing the Questions – avoid reading questions from the history
form. This deflects attention from the client and results in an
impersonal interview process. As a result, the client may feel ill at ease
opening up to formatted questions.

❖ Special Considerations During the Interview

There are three variations in communication must be considered as you interview the
client:
1. Gerontologic Variations in Communication
➢ Age affects and commonly slows the body systems to varying degree.
However, normal aspects of aging do not necessarily equate with a health
problem, so it is important not to approach an interview with an elderly
client assuming that there is a health problem.
➢ When interviewing an older client, you must first assess hearing acuity.
Hearing loss occurs normally with age, and undetected hearing loss is often
misinterpreted as mental slowness or confusion.
➢ Speak clearly and use straightforward language during the interview with
the older adult client. Ask questions in simple terms. Avoid medical jargon
and modern slang. However, do not talk down to the client. Being older
does not mean that the client is slower mentally. Showing respect is very
important. If the older client is mentally confused or forgetful, it is
important to have significant other present during interview to provide or
clarify the data.
2. Cultural Variations in Communication
➢ Ethnic/Cultural variations in communication and self-disclosure styles may
significantly affect the information obtained. Be aware of possible
variations in the communication styles of yourself and the client.
➢ Frequent noted variations in communication styles include:
✓ Reluctance to reveal personal information to strangers for various
culturally-based reasons.
✓ Variation in willingness to openly express emotional distress or pain.
✓ Variation in ability to receive information (listen)
✓ Variation in meaning conveyed by language. For example, a client who
does not speak the predominant language may not know what a
certain medical term or phrase means and, therefore, will not know
how to answer your question. Use of slang with non-native speakers is
discouraged as well. Keep in mind that it is hard enough to learn proper
language, let alone the idiom vernacular. The non-native speaker will
likely have no idea what you are trying to convey.
✓ Variation in use and meaning of nonverbal communication: eye
contact, stance, gestures, demeanor. For example, direct eye contact
 may be perceived as rude, aggressive, or immodest by some cultures
but lack of eye contact may be perceived as evasive, insecure, or
inattentive by other cultures. A slightly bowed stance may indicate
respect in some groups; size of personal space affects one’s
comfortable interpersonal distance; touch may be perceived as
comforting or threatening.
✓ Variation in disease/illness perception: Cultures pecific syndromes or
disorders are accepted by some groups (e.g., in Latin America, susto is
an illness caused by a sudden shock or fright). Variation in past,
present, or future time orientation (e.g., the dominant U.S. culture is
future oriented; other cultures may focus more on the past or present).
✓ Variation in the family’s role in the decision nmaking process: A person
other than the client or the client’s parent may be the major decision
maker about appointments, treatments, or follow-up care for the
client.
➢ You may have to interview a client who does not speak your language. To
perform the best interview possible, it is necessary to use an interpreter.
Possibly the best interpreter would be a culture expert (or culture broker).
Consider the relationship of the interpreter to the client. If the interpreter
is the client’s child or a person of a different sex, age, or social status,
interpretation may be impaired. Also keep in mind that communication
through use of pictures may be helpful when working with some clients.
3. Emotional Variations in Communication
➢ Not every client you encounter will be calm, friendly, and eager to
participate in the interview process. Clients’ emotions vary for a few
reasons.
➢ They may be scared or anxious about their health or about disclosing
personal information, angry that they are sick or about having to have an
examination, depressed about their health or other life events, or they
may have an ulterior motive for having an assessment performed.
➢ Clients may also have some sensitive issues with which they are grappling
and may turn to you for help.
COMPLETE HEALTH HISTORY
The health history is an excellent way to begin the assessment process because it lays the
groundwork for identifying nursing problems and provides a focus for the physical examination.
The importance of the health history lies in its ability to provide information that will assist the
examiner in identifying areas of strength and limitation in the individual’s lifestyle and current
health status. Data from the health history also provide the examiner with specific cues to health
problems that are most apparent to the client. Then these areas may be more intensely examined
during the physical assessment. When a client is having a complete, head-to-toe physical
assessment, collection of subjective data usually requires that the nurse take a complete health
history. The complete health history is modified or shortened when necessary. Taking a health
history should begin with an explanation to the client of why the information is being requested.
❖ Biographic Data
Usually include information that identifies the client, such as name, address, phone
number, gender, and who provided the information—the client or significant others. The
client’s birth date, Social Security number, medical record number, or similar identifying
data may be included in the biographic data section.

The client’s culture, ethnicity, and

subculture may begin to be determined by
collecting data about date and place of birth,
nationality or ethnicity, marital status,
religious or spiritual practices, and primary
and secondary languages spoken, written,
and read. This information helps the nurse
to examine special needs and beliefs that
may affect the client or family’s health care.
A person’s primary language is usually the
one spoken in the family during early
childhood and the one in which the person
thinks. However, if the client was educated
in another language from kindergarten on,
that may be the primary language and the birth language would be secondary.
Gathering information about the client’s educational level, occupation, and working
status at this point in the health history assists the examiner to tailor questions to the
client’s level of understanding. In addition, this information can help to identify possible
client strengths and limitations affecting health status. For example, if the client was
recently downsized from a high-power, high-salary position, the effects of overwhelming
stress may play a large part in his or her health status.
The client is considered the primary source and all others (including the client’s
medical record) are secondary sources.
In some cases, the client’s immediate family or caregiver may be a more accurate
source of information than the client. An example would be an elderly client’s wife who
has kept the client’s medical records for years or the legal guardian of a mentally
compromised client. In any event, validation of the information by a secondary source
may be helpful.
Finally, asking who lives with the client and identifying significant others indicates the
availability of potential caregivers and support people for the client.
❖ Reason(s) for Seeking Health Care
 This category includes two questions: “What is your major health problem or concerns
at this time?” and “How do you feel about having to seek health care?” The first question
assists the client to focus on his most significant health concern and answers the nurse’s
question, “Why are you here?” or “How can I help you?” Physicians call this the client’s
chief complaint (CC), but a more holistic approach for phrasing the question may draw
out concerns that reach beyond just a physical complaint and may address stress or
lifestyle changes.
The second question, “How do you feel about having to seek health care?” encourages
the client to discuss fears or other feelings about having to see a health care provider. For
example, a woman visiting a nurse practitioner states her major health concern: “I found
a lump in my breast.” This woman may be able to respond to the second question by
voicing fears that she has been reluctant to share with her significant others. This question
may also draw out descriptions of previous experiences—both positive and negative—
with other health care providers.
❖ Chief Complaint
Chief complaint is the medical term used to describe the primary problem of the
patient that led the patient to seek medical attention and of which they are most
concerned.
The chief complaint is obtained by the Physician in the initial part of the visit when
the medical history is being taken. It will be elicited by asking the patient what brings
them to be seen? and what major symptoms or problems they are experiencing?
❖ History Taking

▪ Present Health Concern/ Illness

This section of the
health history takes into
account several aspects
of the health problem
and asks questions
whose answers can
provide a detailed
description of the
concern.
First, encourage the
client to explain the
health problem or
symptom in as much
detail as possible by
focusing on the onset, progression, and duration of the problem; signs and symptoms and
related problems; and what the client perceives as causing the problem. You may also ask
the client to evaluate what makes the problem worse, what makes it better, which
treatments have been tried, what effect the problem has had on daily life or lifestyle,
what expectations are held about recovery, and what is the client’s ability to provide self-
care.
Because there are many characteristics to be explored for each symptom, a memory
helper—known as a mnemonic—can help the nurse to complete the assessment of the
sign, symptom, or health concern.
Examples of what the nurse would ask a client with back pain:
1. “When did you first notice the pain in your back? How long have you experienced
it? Has it become worse, better, or stayed the same since it first occurred?”
2. “What does the pain feel like? Where does it hurt the most? Does it radiate or go
to any other part of your body? How intense is the pain? Rate the pain on a scale
of 1 to 10 with 1 being barely noticeable and 10 being the worst pain you have
ever experienced. Do you have any other problems that seem related to this back
pain?”
3. “What do you think caused this problem to start?”
4. “What makes your back hurt more? What makes it feel better? Have you tried any
treatments to relieve the pain such as aspirin or acetaminophen (Tylenol) or
anything else?”
5. “How does the pain affect your life and daily activities?”
6. “What do you think will happen with this problem? Do you expect to get well?
What about your job? Do you think you will be able to continue working?”
The client’s answers to the questions provide the nurse with a great deal of
information about the client’s problem and especially how it affects lifestyle and activities
of daily living. This helps the nurse to evaluate the client’s insight into the problem and
the client’s plans for managing it. The nurse can also begin to postulate nursing diagnoses
from this initial information.
▪ Past Health History
This portion of the health history
focuses on questions related to the
client’s past, from the earliest
beginnings to the present. These
questions elicit data related to the
client’s strengths and weaknesses in
her health history. The data may also
point to trends of unhealthy
behaviors such as being smoking or
lack of physical activity. The
information gained from these
questions assists the nurse to identify risk factors that stem from previous health
problems. Risk factors may be to the client or to his significant others.
Information covered in this section includes questions about birth, growth,
development, childhood diseases, immunizations, allergies, previous health problems,
hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain
experiences, and emotional or psychiatric problems.
Sample questions include:
1. “Can you tell me how your mother described your birth? Were there any
problems? As far as you know, did you progress normally as you grew to
adulthood? Were there any problems that your family told you about or that you
experienced?”
2. “What diseases did you have as a child such as measles or mumps? What
immunizations did you get and are you up to date now?”
3. “Do you have any chronic illnesses? If so, when was it diagnosed? How is it
treated? How satisfied have you been with the treatment?”
4. “What illnesses or allergies have you had? How were the illnesses treated?”
5. “Have you ever been pregnant and delivered a baby? How many times have you
been pregnant/ delivered?”
6. “Have you ever been hospitalized or had surgery? If so, when? What were you
hospitalized for or what type of surgery did you have? Were there any
complications?”
7. “Have you experienced any accidents or injuries? Please describe them.”
8. “Have you experienced pain in any part of your body? Please describe the pain.”
9. “Have you ever been diagnosed with/treated for emotional or mental problems?
If so, please describe their nature and any treatment received. Describe your level
of satisfaction with the treatment.”

▪ Family Health History

As researchers discover more
and more health problems that
seem to run in families and that are
genetically based, the family health
history assumes greater
importance. In addition to genetic
predisposition, it is also helpful to
see other health problems that may
have affected the client by virtue of having grown up in the family and being exposed to
these problems. For example, a gene predisposing a person to smoking has not yet been
discovered but a family with smoking members can affect other members in at least two
ways. First, the second-hand smoke can compromise the physical health of nonsmoking
members; second, the smoker may serve as a negative role model for children, inducing
them to take up the habit as well. Another example is obesity; recognizing it in the family
history can alert the nurse to a potential risk factor. The family history should include as
many genetic relatives as the client can recall. Include maternal and paternal
grandparents, aunts and uncles on both sides, parents, siblings, and the client’s children.
Such thoroughness usually identifies those diseases that may skip a generation such as
autosomal recessive disorders. Include the client’s spouse but indicate that there is no
genetic link. Identifying the spouse’s health problems could explain disorders in the
client’s children not indicated in the client’s family history.