NURS 321 - Health History & Physical Assessment

subjective data

• Patient’s sensations, feelings, perceptions, values, and personal information

• “Reported in their own words”

• Ex: “Patient states ‘Get out.’” or “I’ve been having a lot of stomach pain.”

objective data

• Information that is measurable and directly observed

• Observed through examination techniques

• Ex: blood pressure assessment, hearing a crackle sound in the lungs

Types of health assessment

Comprehensive, ongoing partial, focused, emergency (trauma)

Comprehensive health assessment

conducted upon admission to a healthcare facility

ongoing partial health assessment

conducted at regular intervals (ex: shift assessment)

focused health assessment

• conducted to assess a specific problem (ex: headache)

• ex: if they’re there for chest pain, you just assess cardiac

emergency (trauma) health assessment

• conducted to determine life-threatening or unstable conditions

• ex: gunshot, stabbing, shooting, motor vehicle accident

structure and phases of the interview process

Pre-introductory, introductory, working, summary & closing

Pre Introductory Stage of Interview

• Nurse reviews patient’s medical record

• Doorway assessment - want to always can the room first, making sure there are areas of safety in the room, don’t be backed against the wall with the patient at the door, possibility of injury

Introductory Stage of Interview

• Introduction: explain purpose, assure privacy, develop trust

• Calm down, don’t rapid-fire questions, be comfortable with silence

Working Stage of Interview

• Elicit the core data of the health history

• Ask them questions, why they came to the hospital, allergies, work together with the patient

Summary & Closing Stage of Interview

• Summarize clinical findings, clarify details

• Summarize what’s happening, call bell

• Never say “I’ll be right back” and don’t come back, breaking the trust

  • “Normally I should be here every hour. If I’m not, it’s because I’m with another patient doing the same thing I am with you.”

open-ended questions

a therapeutic verbal communication technique that encourages clients to share detailed information, express feelings, and elaborate rather than answering with a simple ‘yes’ or ‘no’.

closed-ended questions

a verbal technique used to gather specific facts, concise data, or yes/no responses, often utilized during initial assessments or emergency situations

validation technique

• Confirming what the nurse believes they heard or observed to ensure accurate interpretation of the client’s message

• Ex: ‘I hear you saying that your knee hurts most in the morning; is that correct?’

clarification technique

A verbal skill used to gain a clearer understading of vague, ambiguous, or confusing statements made by the patient

reflection technique

• Directing feelings, ideas, or words back to the client to encourage them to explore their emotions

• Ex:

  • Patient: ‘I’m so worried about surgery’

  • Nurse: ‘You’re feeling anxious about this procedure’

sequencing technique

• Placing events in chronological order to investigate cause-and-effect relationships

• Ex: identifying whether medication ingestion occurred before or after nausea began

directing technique

• Focusing the conversation on a specific topic or area that requires further exploration

• Nurse leads the direction of the interview instead of letting the patient control the flow

• It targets exact details like symptoms, timelines, or medication compliance

• Questions often require short answers or a simple yes or no

• Ex: ‘How many times a day do you take your blood pressure medication?’

impact of non-verbal communication

non-verbal cues (such as eye rolling or posture) often have an amplified effect compared to verbal words and are viewed by patients as more reliable indicators of feelings

role of professional appearance in nursing

clean attire, grooming, and appropriate dress convey competence, professionalism, and respect to the client during assessment

demeanor and demeanor’s impact

a nurse’s outward behavior and bearing, which should remain calm, welcoming, professional, and composed to foster trust

facial expressions in patient care

non-verbal cues conveyed through facial muscles that communicate empathy, attentiveness, and acceptance—-or conversely, judgment, disapproval, or impatience

attitude in therapeutic relationships

a non-judgmental, compassionate, and accepting mindset that prioritizes patient-centered care and psychological safety

active listening

a non-verbal and verbal process involving total attention, eye contact, nodding, and processing the underlying meaning of the client’s message

inappropriate eye contact

excessive eye contact (staring/intimidation) or insufficient eye contact (appearing uninterested, anxious, or evasive), both of which impede trust

physical distance and distraction barrier

environmental or personal barriers (ex: multitasking, looking at computers, excessive distance) that signal to the patient a lack of interest or care

standing vs. sitting positioning

standing over a seated client creates an authoritative, threatening dynamic; sitting eye-to-eye fosters equality, comfort, and engagement

biased or leading questions

• Non-therapeutic phrasing that implies a correct answer or judgment

• Ex: ‘You don’t smoke, right?’, leading patients to hide sensitive information

non-judgmental questioning alternative

• Phrasing questions neutrally and non-punitively to elicit truthful health information

• "Ex: ‘I’m not here to judge you, do you use recreational drugs?’

rushing through the interview

a non-therapeutic practice that signals impatience, reduces patient disclosure, and increases the risk of missing critical diagnostic details

reading questions directly

mechanically reading assessment tools word-for-word, which creates a robotic atmosphere, breaks eye contact, and hinders rapport

Non-verbal cue: eye rolling

a dismissal cue conveying annoyance, disbelief, or disrespect, which severely damages nurse-patient rapport

primary goal of therapeutic communication

to build a trusting nurse-patient relationship, gather accurate data, empower the client, and promote health and wellness outcomes

reflective vs. clarifying skills

reflective focuses on mirroring emotional meaning back to the patient, whereas clarifying seeks to eliminate ambiguity or gain clear facts

sequencing example in clinical assessment

asking ‘Did you take your medication before or after you started feeling dizzy?’ to establish a clear temporal relationship between actions and symptoms

optimal seating position for health assessment

seated at a 45-degree angle or directly eye-to-eye with the client, maintaining appropriate personal space without physical barriers in between

gerontologic interviewing methods

allow extra time for responses, account for sensory impairments, accommodate easy fatigue, and pace questions

cultural interviewing considerations

communication style, pain expression, modesty and gender roles, health beliefs, eye contact

emotional interviewing considerations

anxiety or fear, depression, anger or frustration, mental health conditions