Chapter 2
Collecting Subjective Data: The Interview and Health History
AYOMIDE AYODELE
Nursing Interview Guide to Collect Subjective Data from the Client
Questions
Findings
Biographical Data
Name
Gender
Address, phone number
Date and place of birth
Nationality or ethnicity
Marital status
Religious or spiritual practices
Primary and secondary languages spoken, written, and read; birth
language
Educational level
Occupation and working status
Who lives with the client? Identify significant others
Caregivers and support people for the client
Tokoni Bee
Female
V Icon
7139924834
Aug 15, 2001
Born in Lagos,
Nigeria
Nigeria
Single
Christian
EnglishPrimary and
Birth Language
College,
Nursing School
Currently
Unemployed
None
None
Reason for Seeking Health Care
1. What is your major health care or concern?
2. Are you comfortable with seeking care from this organization?
Past experiences good or not?
Stomach Pain
Yes
History of Present Health Concern
(use COLDSPA when appropriate)
1. Character of symptom or condition
Tiredness,
weakness
Nursing Interview Guide to Collect Subjective Data from the Client
2. Onset (when did it begin; better? worse? same?)
pain in the
stomach area
Started about
one week ago,
It has been
getting worse
day by day.
3. Location (where and does it radiate?)
4. Severity (on scale of 1–10?)
5. Pattern (what makes it better? worse?)
6. Associated factors (other associated symptoms? Effect on
leisure or exercise?)
6
Pain
medication
makes
performing
certain
activities
makes it worse
Causes
weakness and
affect school
performance
Past Health History
Problems at birth?
Childhood illnesses?
Immunizations to date?
Acute or chronic adult illnesses (physical, emotional, mental)?
Surgeries?
Pregnancies? Births? Miscarriages? Abortions?
Accidents? Injuries?
Prolonged pain or pain patterns?
Medications
Allergies?
None
None
Complete
None
None
None
None
None
None
None
Family Health History
Recall as many genetic relatives as possible (parents,
grandparents, siblings) with age, longevity, chronic illnesses (i.e.,
heart disease, stroke, diabetes, cancer, arthritis, Alzheimer’s).
Maternal side
has Diabetes
Review of Systems
Skin, hair, and nails: Skin color, temperature, condition, excessive
sweating, rashes, lesions, balding, dandruff, condition of nails
Client does not
sweat
excessively,
Nursing Interview Guide to Collect Subjective Data from the Client
Head and neck: Headache, swelling, stiffness of neck, difficulty
swallowing, sore throat, enlarged lymph nodes
Eyes: Vision, eye infections, redness, 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, drainage from ears,
dizziness, exposure to loud noises
Mouth, throat, nose, and sinuses: Condition of 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, pain, shortness
of breath during routine activity, orthopnea, cough or sputum,
hemoptysis, respiratory infections
Breasts and regional lymphatics: Lumps or discharge from nipples,
dimpling or changes in breast size, swollen or tender lymph nodes
in axilla
Heart and neck vessels: Last blood pressure, ECG tracing or
findings, chest pain or pressure, palpitations, edema
Peripheral vascular: Swelling, or edema, of legs and feet; pain;
cramping; sores on legs; color or texture changes on the legs or
feet
Abdomen: Indigestion, difficulty swallowing, nausea, vomiting,
abdominal pain, gas, jaundice, hernias
Client does not
experience
balding.
No difficulty
swallowing,
No Sore throat
No eye pain,
No excessive
tearing
No buzzing or
ringing in ear,
No ear
drainage
Client does not
snore,
There is no
Problem with
tooth or gum.
No Shortness
of breath,
No difficulty
breathing
No discharge
from Nipple
area,
No changes in
Breast size
No Chest Pain,
Client Cannot
recall last
blood pressure
measurement.
No swelling on
leg,
No Cramps or
Pain on leg
Indigestion
occurs
Sometimes,
No sign of
Nursing Interview Guide to Collect Subjective Data from the Client
Male genitalia: Excessive or painful urination, 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 transmitted diseases;
voiding problems (e.g., 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 with defecation,
hemorrhoids, blood in stool, constipation, diarrhea
Musculoskeletal: Swelling, redness, pain, stiffness of joints, ability
to perform activities of daily living, muscle strength
Neurologic: General mood, behavior, depression, anger,
concussions, headaches, loss of strength or sensation,
coordination, difficulty speaking, memory problems, strange
thoughts and/or actions, difficulty learning
Vomiting.
CLIENT IS
FEMALE
Client Urinates
a lot after
drinking a lot
of water,
No difficulty
with urinating,
No sexual
problems
identified
No problem
with defecation
No diarrhea or
constipation
No stiffening of
Joint
Client have not
been able to
perform ADL
efficiently due
to the current
condition.
Client gets
angry and sad
when she gets
stomach pain
Client
experience loss
of strength and
coordination
during Pain
Lifestyle and Health Practices Profile
Description of Typical Day
“Please tell me what an average or typical day is for you. Start
with awakening in the morning and continue until bedtime.”
Starts day at
7am for
school, go to
the gym,
study, and go
Nursing Interview Guide to Collect Subjective Data from the Client
to bed around
8pm.
Nutrition and Weight Management
• “What do you usually eat during a typical day? Please tell me the
kinds of foods you prefer, how often you eat throughout the day,
and how much you eat.”
• “Do you eat out at restaurants frequently?”
• “Do you eat only when hungry? Do you eat because of boredom,
habit, anxiety, depression?”
• “Who buys and prepares the food you eat?”
• “Where do you eat your meals?”
• “How much and what types of fluids do you drink?”
Activity Level and Exercise
• “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
• “Tell me about your sleeping patterns.”
• “Do you have trouble falling asleep or staying asleep?”
• “How much sleep do you get each night?”
• “Do you feel rested when you awaken?”
• “Do you nap during the day? How often and for how long?”
• “What do you do to help you fall asleep?”
Substance Use
• “How much beer, wine, or other alcohol do you drink on the
average?”
• “Do you drink coffee or other beverages containing caffeine
(e.g., 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?”
• “Have you ever used, or do you now use, recreational drugs?
Describe any usage.”
• “Do you take vitamins or herbal supplements? If so, what?”
Breakfast
oatmeal,
smoothies and
snacks for
lunch, Pasta
for dinner
Food is
purchased and
prepared by
client
Client goes to
the gym at
least four
times a week
Client does
weightlift and
cardio
Client gets 6-8
hours of sleep
at night
Sometimes
nap during the
day
Client does not
drink or smoke
Client does not
drink Coffee,
she drinks
water
Uses OTC pain
medications
Nursing Interview Guide to Collect Subjective Data from the Client
Self-Concept and Self-Care Responsibilities
• “What do you see as your talents or special abilities?”
• “How do you feel about yourself? About your appearance?”
• “Can you tell me what activities you do to keep yourself safe,
healthy, or to prevent disease?”
• “Do you practice safe sex?”
• “How do you keep your home safe?”
• “Do you drive safely?”
• “How often do you have medical checkups or screenings?”
• “How often do you see the dentist or have your eyes (vision)
examined?”
Social Activities
“What do you do for fun and relaxation?”
• “With whom do you socialize most 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?”
Client stays
safe by being
conscious of
her
environment
Talent is
Dancing
Client goes to
the gym and
goes to
therapy to
relax, client
eats.
Client feels
safe in her
community
Relationships
“Who is (are) the most important person(s) in your life? 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
“What is most important to you in life?”
• “What do you hope to accomplish in your life?”
• “Do you have a religious affiliation? Is 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?”
Education and Work
• “Tell me about your experiences in school or about your
education.”
• “Are you satisfied with the level of education you have? Do you
Most
important
people are
family
Nice family
and it was
great
growing up
with family.
Getting closer
to God is the
most
important
thing in life
Praying and
meditating
gives strength
and hope
Nursing school
is stressful
Father
Nursing Interview Guide to Collect Subjective Data from the Client
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 coworkers?”
• “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
• “What types of things make you angry?”
• “How would you describe your stress level?”
• “How do you manage anger or stress?”
• “What do you see as the greatest stressors in your life?”
• “Where do you usually turn for help in a time of crisis?”
Environment
• “What risks are you aware of in your environment such as in
your home, neighborhood, on the job, or any other activities in
which you participate?”
• “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.”
supports client
financially
Being rude
makes her
angry
Going to the
gym and
watching
Netflix relieves
stress.
Client puts on
gloves when
coming in
contact with
chemicals
Believes that
anyone can be
a victim of
violence