Chapter 2 Collecting Subjective Data: The
Interview and Health History
Learning Objectives
1. Discuss the purpose for each of the four phases of a client interview.
a. Preintroductory- nurse reviews med. Record BEFORE meeting w
client. Knowing some info may help w interview.
i. If client has been in sys. This may reveal helpful info, such as:
difficulty hearing in one ear/ past health history.
ii. If there is no medical record, the nurse will need to RELY on
the interviewing skills, to obtain valid & reliable data from
client.
b. Introductory- nurse explains purpose of interview, types of questions to
be asked, reason for note taking, & assures client that confidential info
will remain confidential.
i. Nurse must: make sure client is COMFORTABLE (physically
& emotionally) & privacy
ii. Interview: conducted @ eye level (shows respect & equality)
1. Nurse: develop trust & rapport (IMPORTANT); convey
a sense of priority & interest in clients
a. Developing rapport depends on verbal &
nonverbal communications from the NURSE
ii. We are trying to establish a relationship:
1. If unsuccessful our data might not be accurate
b. Working (lengthy part)- the nurse receives info from the patient, such as:
major biographical data, reasons for seeking care, history of present
health concern, past health history, fam. History, review of B.S. (ROS) ,
lifestyle, & developmental level.
i. Nurse: listens, observes cues, & uses critical thinking skills to
interpret & validate info.
ii. Nurse & client: work together to identify client's problems &
goals
iii. Ask variety of questions, get to know patient
b. Summary/closing-
i. Nurse: summarizes info obtained & validates problems/goals w/
client.
1. Identifies & discusses POSSIBLE plans to resolve the
problem w/ client
2. Asks if anything else concerns the client/ has any questions.
2. Describe effective verbal and nonverbal communication techniques to collect
subjective client data.
a. Nonverbal
i. Appearance- professional. (ex: comfy & neat clothes; lab
coat/uniform); name tag & credential must be visible; neat
hairstyle; minimal jewelry; short fingernails
ii. Demeanor- professional.
1. Focus on client & interview/assessment. Don’t enter
loudly
2. Greet client calm & by name.
3. Full attention on client
4. professional distance :Avoid overwhelmingly
friendliness
, ii. Facial expression- shows what you truly think
1. Keep it neutral
2. If feeling upset, then briefly explain to avoid making the
client feel it is directed at them & helps build a trusting
relationship.
3. USE RIGHT EXPRESSIONS AT THE RIGHT TIME
ii. Attitude- NONJUDGMENTAL ATTITUDE
1. ALL clients should be ACCEPTED (beliefs, ethnicity,
lifestyle)
2. Don’t' act like you're superior/ disgusted.
1. Especially when they’re telling you something
bc it may cause the pt to feel uncomfortable &
may withhold info
3. Make the client feel comfortable
4. Do not impose YOUR OWN sense of belief/ lecture the
client
5. Accept the client, be understanding of the habit, and
work together to improve the client’s health
ii. Silence- periods of silence allow you & client to reflect &
organize thoughts = accurate reporting & data collection
iii. Listening- MOST IMPORTANT SKILL TO LEARN &
DEVELOP
1. Effective listening- maintain good eye contact, smile/
appropriate facial expression, open body positions
2. Avoid bias
3. KEEP AN OPEN MIND
4. Avoid: crossing arms, sitting back, thinking about other
things, looking @ phone
5. Takes concentration & practice
ii. Avoid:
1. Excessive/ insufficient eye contact
2. Distracton: may tell pt you don’t care
3. Distance: not too close/ far
b. Verbal
i. Open-ended questions- used to elicit client's feelings &
perceptions
1. Begin w/ how/what (ex: how have you been feeling lately?)
2. Requires the pt to give you > 1 word response from
client & encourage description
3. May help w/ revealing significant data about health status
4. Ex: Imagine yourself interviewing an elderly male client
who is at the primary care provider’s office because of
diabetic complications. He mentions casually to you,
“Today is the 2-month anniversary of my wife’s death from
cancer.” Failure to follow up with an open-ended question
such as “How does this make you feel?” may result in the
loss of important data that could provide clues to the
client’s current state of health
ii. Close-ended questions- Use to obtain facts & focus on specific
info
1. Begin w/ when/did (ex: when did your headache start)
2. Keeps interview on course & clarify/ obtain more
accurate info
3. For example, in response to the open-ended question
"How have you been feeling lately?" the client says,
Interview and Health History
Learning Objectives
1. Discuss the purpose for each of the four phases of a client interview.
a. Preintroductory- nurse reviews med. Record BEFORE meeting w
client. Knowing some info may help w interview.
i. If client has been in sys. This may reveal helpful info, such as:
difficulty hearing in one ear/ past health history.
ii. If there is no medical record, the nurse will need to RELY on
the interviewing skills, to obtain valid & reliable data from
client.
b. Introductory- nurse explains purpose of interview, types of questions to
be asked, reason for note taking, & assures client that confidential info
will remain confidential.
i. Nurse must: make sure client is COMFORTABLE (physically
& emotionally) & privacy
ii. Interview: conducted @ eye level (shows respect & equality)
1. Nurse: develop trust & rapport (IMPORTANT); convey
a sense of priority & interest in clients
a. Developing rapport depends on verbal &
nonverbal communications from the NURSE
ii. We are trying to establish a relationship:
1. If unsuccessful our data might not be accurate
b. Working (lengthy part)- the nurse receives info from the patient, such as:
major biographical data, reasons for seeking care, history of present
health concern, past health history, fam. History, review of B.S. (ROS) ,
lifestyle, & developmental level.
i. Nurse: listens, observes cues, & uses critical thinking skills to
interpret & validate info.
ii. Nurse & client: work together to identify client's problems &
goals
iii. Ask variety of questions, get to know patient
b. Summary/closing-
i. Nurse: summarizes info obtained & validates problems/goals w/
client.
1. Identifies & discusses POSSIBLE plans to resolve the
problem w/ client
2. Asks if anything else concerns the client/ has any questions.
2. Describe effective verbal and nonverbal communication techniques to collect
subjective client data.
a. Nonverbal
i. Appearance- professional. (ex: comfy & neat clothes; lab
coat/uniform); name tag & credential must be visible; neat
hairstyle; minimal jewelry; short fingernails
ii. Demeanor- professional.
1. Focus on client & interview/assessment. Don’t enter
loudly
2. Greet client calm & by name.
3. Full attention on client
4. professional distance :Avoid overwhelmingly
friendliness
, ii. Facial expression- shows what you truly think
1. Keep it neutral
2. If feeling upset, then briefly explain to avoid making the
client feel it is directed at them & helps build a trusting
relationship.
3. USE RIGHT EXPRESSIONS AT THE RIGHT TIME
ii. Attitude- NONJUDGMENTAL ATTITUDE
1. ALL clients should be ACCEPTED (beliefs, ethnicity,
lifestyle)
2. Don’t' act like you're superior/ disgusted.
1. Especially when they’re telling you something
bc it may cause the pt to feel uncomfortable &
may withhold info
3. Make the client feel comfortable
4. Do not impose YOUR OWN sense of belief/ lecture the
client
5. Accept the client, be understanding of the habit, and
work together to improve the client’s health
ii. Silence- periods of silence allow you & client to reflect &
organize thoughts = accurate reporting & data collection
iii. Listening- MOST IMPORTANT SKILL TO LEARN &
DEVELOP
1. Effective listening- maintain good eye contact, smile/
appropriate facial expression, open body positions
2. Avoid bias
3. KEEP AN OPEN MIND
4. Avoid: crossing arms, sitting back, thinking about other
things, looking @ phone
5. Takes concentration & practice
ii. Avoid:
1. Excessive/ insufficient eye contact
2. Distracton: may tell pt you don’t care
3. Distance: not too close/ far
b. Verbal
i. Open-ended questions- used to elicit client's feelings &
perceptions
1. Begin w/ how/what (ex: how have you been feeling lately?)
2. Requires the pt to give you > 1 word response from
client & encourage description
3. May help w/ revealing significant data about health status
4. Ex: Imagine yourself interviewing an elderly male client
who is at the primary care provider’s office because of
diabetic complications. He mentions casually to you,
“Today is the 2-month anniversary of my wife’s death from
cancer.” Failure to follow up with an open-ended question
such as “How does this make you feel?” may result in the
loss of important data that could provide clues to the
client’s current state of health
ii. Close-ended questions- Use to obtain facts & focus on specific
info
1. Begin w/ when/did (ex: when did your headache start)
2. Keeps interview on course & clarify/ obtain more
accurate info
3. For example, in response to the open-ended question
"How have you been feeling lately?" the client says,
