Interview Guide to collect Subjective Data from the Client

Current Symptoms

1. Are you experiencing pain now or have you had pain in the past 24 hours?
2. Where is the pain located?
3. Does it radiate or spread?
4. Are there any other concurrent symptoms?
accompanying the pain?
5. When did the pain start?
6. What were you doing when the pain first started?
7. Is the pain continuous or intermittent?
8. (Ask for intermittent pain.) How often do the episodes occur and how long do they last?
9. Describe in your own words the quality of pain.
10. What factors relieve your pain?
11. What factors increase your pain?
12. Are you on any therapy to manage your pain?

Past History

1. Have you had any previous experience with pain?

Family History

1. Does anyone in your family experience pain?

2. How does pain affect your family?

Lifestyles and Health Practices

1. What are your concerns about pain?

2. What are your concerns about the pans effect on

a. general activity?
b. Mood/emotions?
c. concentration
d. physical ability?
e. work?
f. relations with other people?
g. sleep?
h. appetite?
i. enjoyment of life?
Current Symptoms: How to ask these questions?
1. Experiencing Pain: Are you currently experiencing pain, or have you had pain within the
past 24 hours?

2. Location of Pain: Where is the pain located? Please describe the specific area.

3. Radiation or Spread: Does the pain radiate or spread to other parts of your body?

4. Concurrent Symptoms: Are there any other symptoms accompanying the pain?

5. Onset of Pain: When did the pain start? Can you recall a specific time or event?

6. Trigger: What were you doing when the pain first started? Any specific activity or
movement?

7. Continuous or Intermittent: Is the pain continuous or does it come and go?

8. Intermittent Pain: If the pain is intermittent, how often do the episodes occur, and how
long do they last?

9. Quality of Pain: In your own words, how would you describe the quality of the pain (e.g.,
sharp, dull, burning)?

10. Pain Relief Factors: What factors seem to relieve your pain? Any specific actions or
positions?

11. Aggravating Factors: Conversely, what factors tend to increase your pain?

12. Pain Management Therapy: Are you currently using any therapy or treatments to manage
your pain?

Current Symptoms: Rationale of asking these questions.

1. Presence of Pain: Determines if the patient is currently in pain or has experienced pain
recently, which helps in immediate assessment and management.

2. Location of Pain: Pinpoints the specific area where the pain is occurring, aiding in
diagnosis.

3. Radiation or Spread: Determines if the pain is localized or if it spreads to other areas,

which can provide clues to the underlying cause.

4. Concurrent Symptoms: Identifies any other symptoms that might be associated with the
pain, aiding in diagnosis and treatment planning.

5. Onset of Pain: Provides information about when the pain began, which can help identify
triggers or underlying causes.

6. Activity During Onset: Helps to identify any specific activities or events that may have
triggered the pain, aiding in diagnosis and treatment.
 7. Continuous or Intermittent: Determines if the pain is constant or comes and goes, which
can help in understanding the nature of the pain and guiding treatment.

8. Frequency and Duration of Intermittent Pain: If the pain is intermittent, this helps in
understanding the pattern and severity of the episodes.

9. Quality of Pain: Allows the patient to describe the nature of their pain (e.g., sharp, dull,
burning), aiding in diagnosis and treatment.

10. Factors Relieving Pain: Identifies any activities or treatments that alleviate the pain,
guiding management strategies.

11. Factors Increasing Pain: Identifies triggers or exacerbating factors, helping to avoid or
manage them.

12. Pain Management Therapy: Determines if the patient is already undergoing treatment for
pain management, which informs further management plans.

Past history / Family History / Lifestyle and health practices: How to

perform/ask.
1. Past History:

o Previous Experience with Pain: If you’ve had any previous experiences with pain
(such as injuries, chronic conditions, surgeries, or other health issues), please share
those details.

2. Family History:

o Does anyone in your family experience pain?: Understanding family history helps
identify genetic predispositions or shared environmental factors related to pain. If
close relatives (parents, siblings, grandparents) experience pain, please provide that
information.

o How does pain affect your family?: Consider how pain impacts family dynamics,
caregiving responsibilities, and emotional well-being within your family unit.

3. Lifestyles and Health Practices Related to Pain:

o Concerns About Pain: What specific concerns do you have regarding pain? Are
there particular aspects of pain that worry you?

o Impact of Pain on Various Aspects:

▪ General Activity: How does pain affect your ability to engage in daily
activities?

▪ Mood/Emotions: Does pain influence your emotional well-being or mood?

▪ Concentration: Is pain affecting your ability to focus or concentrate?

 ▪ Physical Ability: How does pain impact your physical abilities (e.g., mobility,
strength)?

▪ Work: Does pain interfere with your work or productivity?

▪ Relations with Others: How does pain affect your interactions with other
people (family, friends, colleagues)?

▪ Sleep: Does pain disrupt your sleep patterns?

▪ Appetite: Is your appetite affected by pain?

▪ Enjoyment of Life: How does pain impact your overall enjoyment of life?

Past History / Family History / Lifestyle and health practices: Rationale

Past History:

1. Previous Experience with Pain: Provides insight into the patient's medical history and any
previous encounters with pain.

Family History:

1. Family Experience with Pain: Determines if pain conditions run in the family, which can
indicate genetic predispositions or shared environmental factors.

2. Impact on Family: Understands how pain affects not only the individual but also their
family dynamics and support systems.

Lifestyles and Health Practices

1. Concerns About Pain: This question aims to understand the patient's overarching worries or
fears related to their pain, which can vary widely among individuals and may encompass aspects
such as the severity of pain, potential causes, prognosis, or impact on daily life.

2. Concerns About Pain's Effects:

a. General Activity: Evaluates how pain limits or interferes with the patient's ability to engage in
everyday activities, providing insight into the extent of functional impairment.

b. Mood/Emotions: Explores the emotional impact of pain, including feelings of frustration,

sadness, anxiety, or depression, which can significantly affect overall well-being.

c. Concentration: Assesses the cognitive effects of pain, such as difficulties focusing, memory
problems, or reduced mental clarity, which can impact various aspects of daily life.

d. Physical Ability: Determines how pain affects the patient's physical capabilities, including
mobility, strength, coordination, and flexibility, which can influence their independence and quality
of life.
e. Work: Examines the impact of pain on the patient's ability to perform job-related tasks, maintain
employment, or pursue career goals, addressing concerns about productivity, absenteeism, or job
satisfaction.

f. Relations with Other People: Explores how pain affects the patient's interactions and
relationships with family, friends, colleagues, or caregivers, considering concerns about social
isolation, dependence, communication, or support networks.

g. Sleep: Investigates the effects of pain on sleep quality, duration, and patterns, including
difficulties falling asleep, staying asleep, or experiencing restorative sleep, which can exacerbate
pain and impair overall well-being.

h. Appetite: Assesses changes in appetite, eating habits, or nutritional intake due to pain,
considering concerns about weight loss, malnutrition, dietary restrictions, or coping strategies
such as emotional eating.

i. Enjoyment of Life: Explores the broader impact of pain on the patient's overall enjoyment,
satisfaction, and fulfillment in life, including leisure activities, hobbies, interests, and personal
goals, addressing concerns about loss of pleasure or meaningful engagement.

Physical Assessment Guide to Collect Objective Client Data

General Observations

1. Observe posture.

2. Observe facial expression

3. Inspect joints and muscles.

4. Observe skin for scars. lesions, rashes, changes, or discoloration.

Vital Signs

I. Measure heart rate.

2. Measure respiratory rate,

3. Measure blood pressure.

Using the description of pain and your findings ‘Above, continue the assessment. Refer to the
physical assessment chapter. appropriate for affected body area.

How to perform?
General Observations:

1. Posture: Observe the client's posture while they are sitting or standing. Note any
abnormalities such as slouching, leaning to one side, or difficulty maintaining an upright
position.
 2. Facial Expression: Assess the client's facial expression for signs of pain, discomfort,
anxiety, or distress. Note any asymmetry or abnormalities in facial features.

3. Joints and Muscles: Inspect the client's joints and muscles for any swelling, deformities, or
limitations in range of motion. Palpate the joints for warmth, tenderness, or crepitus.

4. Skin: Inspect the client's skin for any scars, lesions, rashes, changes in color or texture, or
signs of trauma. Pay attention to any areas of redness, swelling, or inflammation.

Vital Signs:

1. Heart Rate: Measure the client's heart rate by palpating the radial pulse or using a
stethoscope to auscultate the apical pulse. Count the number of beats per minute (bpm).
Note any irregularities in rhythm or strength.

2. Respiratory Rate: Measure the client's respiratory rate by observing the rise and fall of the
chest or abdomen. Count the number of breaths per minute (bpm) while the client is at rest.
Note any signs of labored breathing, shallow breathing, or use of accessory muscles.

3. Blood Pressure: Measure the client's blood pressure using a sphygmomanometer and
stethoscope or an automated blood pressure monitor. Place the cuff around the client's
upper arm at heart level, inflate the cuff to a pressure higher than the client's systolic
pressure, then slowly deflate the cuff while listening for the Korotkoff sounds. Note the
systolic and diastolic pressures.

Rationale
General Observations

1. Observe Posture: Assess any alterations in posture that may indicate discomfort or pain,
such as guarding or favoring a particular body part.
2. Observe Facial Expression: Look for signs of pain or discomfort in the patient's facial
expressions, such as grimacing, furrowing of the brow, or clenched jaw.
3. Inspect Joints and Muscles: Examine the affected joints and muscles for swelling,
tenderness, redness, or signs of inflammation, which may indicate underlying pathology or
injury.
4. Observe Skin: Check the skin around the area of pain for any abnormalities such as scars,
lesions, rashes, changes in texture, or discoloration, which could provide additional clues
to the cause of pain.

Vital Signs:

1. Measure Heart Rate: Assess the patient's heart rate for any changes, as pain can
sometimes lead to an increase in heart rate due to sympathetic nervous system activation.
2. Measure Respiratory Rate: Monitor the patient's respiratory rate, as pain can affect
breathing patterns, leading to shallow or rapid breathing.
3. Measure Blood Pressure: Evaluate the patient's blood pressure, as pain can sometimes
cause an increase in blood pressure due to the body's stress response.
Rationale:

The rationale behind continuing the assessment in this manner is to gather objective data that
complements the patient's subjective description of pain. By observing general indicators of
discomfort, assessing specific physical signs related to the affected body area, and measuring vital
signs, healthcare providers can obtain a more comprehensive understanding of the patient's pain
experience and its potential physiological effects. This holistic approach enables clinicians to make
informed decisions regarding diagnosis, treatment, and ongoing management of the patient's pain
condition. Additionally, identifying any abnormalities or changes in vital signs can prompt further
evaluation or intervention to address the underlying cause of pain and optimize patient care.