Chapter 2: Collecting Subjective Data: The Interview and Health History (Vocabulary Flashcards)

Phases of the Interview

  • Preintroductory Phase

    • The nurse reviews the medical record before meeting the client to assist with conducting the interview. This helps reveal the client's past health history and reason for seeking care.

  • Introductory Phase

    • Introduction of the nurse to the client

    • Explaining the purpose of the interview

    • Discussing the types of questions that will be asked

    • Explaining the reason for taking notes

    • Assuring the client that confidential information will remain confidential

    • Ensuring the client is comfortable and has privacy

    • Developing trust and rapport using verbal and nonverbal skills

  • Working Phase

    • Phase 2 (biographical data and health history components) and Phase 3 (analysis and collaboration)

    • Phase 2 includes:

    • Biographical data

    • Reasons for seeking care

    • History of present health concern

    • Past health history

    • Family history

    • Review of body systems for current health problems

    • Lifestyle and health practices and developmental level

    • Phase 3 includes:

    • Listening, observing cues, and using critical thinking skills to interpret and validate information

    • Collaborating with the client to identify the client’s problems and goals

  • Summary and Closing Phase

    • Summarizing information obtained during the working phase

    • Validating problems and goals with the client

    • Identifying and discussing possible plans to resolve the problem with the client

    • Asking if anything else concerns the client and if there are any further questions

Question and Answer Highlights

  • Question #1: Is the statement true or false? A client’s feelings and perceptions may be recorded as subjective data.

    • Answer: True. A client’s feelings and perceptions may be recorded as subjective data.

  • Question #2: Is the following statement true or false? The nurse should use closed-ended questions to elicit the client’s feelings and perceptions.

    • Answer: False. The nurse should use open-ended questions to elicit the client’s feelings and perceptions. Closed-ended questions are used to obtain facts and to focus on specific information.

  • Question #3: Which sign in a genogram indicates adoption?

    • Choices: a. Horizontal dotted line; b. Vertical dotted line; c. An X in a circle; d. An X in a square

    • Answer: b. A vertical dotted line. Rationale: In a genogram, a vertical dotted line may indicate adoption. A horizontal dotted line indicates the client’s spouse. An X in a circle indicates a deceased female client. An X in a square indicates a deceased male client.

Communication in the Interview

Nonverbal Communication

  • Components:

    • Appearance

    • Demeanor

    • Facial expression

    • Attitude

    • Silence

    • Listening

Nonverbal Communication to Avoid

  • Excessive or insufficient eye contact

  • Distraction and distance

  • Standing (i.e., maintaining appropriate posture and proximity)

Verbal Communication

  • Open-ended questions

  • Closed-ended questions

  • Laundry list

  • Rephrasing

  • Well-placed phrases

  • Inferring

  • Providing information

  • Verbal Communication to Avoid

    • Biased or leading questions

    • Rushing through the interview

    • Reading the questions

  • Special Considerations

    • Gerontologic variations

    • Cultural variations

    • Emotional variations

  • COLDSPA mnemonic (analyze a client symptom)

    • Character

    • Onset

    • Location

    • Duration

    • Severity

    • Pattern

    • Associated factors

Adapting the Interview for Different Situations

  • Interacting with an Anxious Client

    • Provide simple, organized information in a structured format

    • Explain who you are, your role, and your purpose

    • Ask simple, concise questions

    • Avoid becoming anxious yourself

    • Do not hurry

    • Decrease external stimuli

  • Interacting with an Angry Client

    • Approach calmly, reassuringly, in a controlled manner

    • Allow the client to vent feelings

    • Avoid arguments or touching

    • Obtain help from other health professionals as needed

    • Facilitate personal space to avoid threats

    • Never allow the client to position between you and the door

  • Interacting with a Depressed Client

    • Express interest and understanding in a neutral manner

    • Avoid using an upbeat, encouraging tone

  • Interacting with a Manipulative Client

    • Provide structure and set limits

    • Differentiate between manipulation and a reasonable request

    • Obtain an objective opinion from other nursing colleagues

  • Interacting with a Seductive Client

    • Set firm limits on overt sexual behavior; avoid responding to subtle seduction

    • Encourage more appropriate coping in relating to others

    • If overt sexuality continues, do not interact without a witness

    • Report inappropriate behavior to a supervisor

  • Discussing Sensitive Issues

    • Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality

    • Ask simple questions in a nonjudgmental manner

    • Allow time for ventilation of feelings as needed

    • If uncomfortable or not competent to discuss, consider referrals as appropriate

Health History: Structure and Content

Major Categories

  • Biographical data

  • Reasons for seeking health care

  • History of present health concern

  • Past health history

  • Family health history

  • Review of systems for current health problems

  • Lifestyle and health practices

  • Developmental level

Health History — Biographical Data (Examples)

  • #1: Name, Address, Phone, Gender, Provider of history (patient or other), Birth date, Place of birth

  • #2: Race or ethnic background, Primary and secondary languages (spoken and read), Marital status, Religious or spiritual practices, Educational level, Occupation, Significant others or support persons (availability)

Genogram Review

  • Question: Which sign indicates adoption in a genogram?

    • Answer: Vertical dotted line (b).

    • Rationale (summary):

    • Vertical dotted line = adoption

    • Horizontal dotted line = spouse

    • X in a circle = deceased female

    • X in a square = deceased male

Review of Body Systems

Body Systems: Part 1

  • Skin, hair, nails

  • Head, neck

  • Eyes

  • Ears

  • Mouth, throat, nose, sinuses

  • Thorax, lungs

Body Systems: Part 2

  • Breasts, regional lymphatics

  • Heart, neck vessels

  • Peripheral vascular

  • Abdomen

  • Genitalia

  • Anus, rectum, prostate

  • Musculoskeletal

  • Neurologic

Lifestyle and Health Practices

Lifestyle and Health Practices — Part 1

  • Description of typical day (AM to PM)

  • Nutrition and weight management

  • 24-hour dietary intake (foods and fluids)

  • Who purchases and prepares meals

  • Activity on a typical day and exercise habits/patterns

  • Rest and sleep habits and patterns

  • Medication and substance use

  • Self-concept and self-care responsibilities

Lifestyle and Health Practices — Part 2

  • Social activities

  • Relationships

  • Values and belief system

  • Past, present and future education and work

  • Type of work, level of job satisfaction, work stressors

  • Stress levels and coping strategies

  • Residency, environment, neighborhood, environmental risks

Notes on Key Concepts and Cross-cutting Points

  • The four objective learning outcomes map to understanding interview phases, communication techniques, and adaptation for special populations (older adults, emotional issues, ethnicity).

  • The interview is a structured process designed to collect subjective data that complements objective data from the medical record and physical examination.

  • Subjective data vs. objective data distinctions: feelings, perceptions, and experiences are subjective data; measurable findings from exam/tests are objective data.

  • Privacy, confidentiality, and trust are foundational to effective interviewing.

  • Open-ended questions are preferred for eliciting feelings and perceptions; closed-ended questions for clarifying facts.

  • Avoid biased, leading, or rushed questions to maintain neutrality and rapport.

  • Special scenarios (anxious, angry, depressed, manipulative, seductive) require tailored communication strategies and, when necessary, involvement of colleagues or supervisors to ensure safety and appropriateness.

  • The genogram is a useful tool for visually representing family health history, with specific symbols indicating relationships, adoptions, and terminations (death).

  • The COLDSPA mnemonic provides a structured framework to analyze symptoms, guiding comprehensive symptom assessment.

  • The health history sections ensure a comprehensive capture of demographic data, reasons for care, current and past health issues, family history, systems review, lifestyle, and developmental context for holistic care.

Quick Reference Tables (Condensed)

  • Phases of the Interview: Preintroductory → Introductory → Working → Summary/Closing

  • VerbalTechniques: Open-ended, Closed-ended, Laundry list, Rephrasing, Inferring, Providing information

  • Nonverbal Cautions: Eye contact balance, proximity, posture, listening cues

  • COLDSPA: Character, Onset, Location, Duration, Severity, Pattern, Associated factors

  • Genogram Symbols: Vertical dotted line = adoption; Horizontal dotted line = spouse; X in circle = deceased female; X in square = deceased male