PREPARING FOR THE

ASSESSMENT
- The OBJECTIVE data support the SUBJECTIVE
DATA: what you observe confirms what the person
is stating.
- CUES- subjective or objective data observed by the
nurses; it is what the client says, or what the nurse
can see, hear, feel, smell or measure.
- INFERENCE- the nurse interpretation or conclusion
based on the cues.
- (Example: red, swollen wound = infected wound;
Dry skin= dehydrated)
COLLECTING SUBJECTIVE DATA:
The Interview and Health
History
- Subjective Data - sensations or symptoms (e.g.,
pain, hunger), feelings (e.g., happiness, sadness),
perceptions, desires, preferences, beliefs, ideas,
values, and personal information that can be
elicited and verified only by the client.
- Subjective data provide clues to possible
physiologic, psychological, and sociologic problems.
They also provide the nurse with information that
may reveal a client’s risk for a problem as well as
areas of strengths for the client
-For accurate subjective data, learn to use effective
interviewing skills with a variety of clients in
different settings.
 HEALTH HISTORY GUIDELINES

INTERVIEW

• A planned communication or a conversation

with a purpose
Interviewing
Obtaining a valid nursing health history requires professional,
interpersonal, and interviewing skills. The nursing interview is a
communication process that has two focuses:

1.Establishing rapport and a trusting relationship with the client

to elicit accurate and meaningful information.

2.Gathering information on the client’s developmental,

psychological, physiologic, sociocultural, and spiritual statuses
to identify deviations that can be treated with nursing and
collaborative interventions or strengths that can be enhanced
through nurse–client collaboration.
 PURPOSES OF INTERVIEW

1. Get or give information

2. Identify problems of mutual concern
3. Evaluate change
4. Teach
5. Provide counseling or therapy
 Approaches to Interviewing

1. DIRECTIVE INTERVIEW

• Highly structured, elicits specific information

• Nurse establishes purpose of and controls the
interview
• Used to gather and get information when time is
limited
 Approaches to Interviewing

2. NON-DIRECTIVE INTERVIEW
• Rapport building
• Nurse allows client to control the purpose, subject
matter, and pacing.

NOTE: A combination of Directive and Non-directive

interview approaches is usually appropriate during
information-gathering interview.
TYPES OF COMMUNICATION
VERBAL-
is the use of words to share information with other
people. It can therefore include both spoken and
written communication
NON-VERBAL-
• is the transmission of messages or signals through a
nonverbal platform such as eye contact, facial
expressions, gestures, posture, use of objects and
body language. It includes the use of social cues,
kinesics, distance and physical
environments/appearance, of voice and of touch.
NON VERBAL COMMUNICATION

• APPEARANCE
• First take care to ensure that your appearance is
professional. The client is expecting to see a health
professional; therefore, you should look the part.
• Wear comfortable, neat clothes and a lab coat or
uniform, your hair should be neat and not in any
extreme style; some nurses like to wear long hair
pulled back. Fingernails should be short and neat;
jewelry should be minimal.
NON VERBAL COMMUNICATION

• DEMEANOR
- Maintain professional distance, do not be “touchy”
- Do not enter the room laughing loudly, yelling to a
coworker or muttering under your breath
- Do not be overwhelmingly friendly
- Greet the client calmly and focus your attention to
her and the interview
NON VERBAL COMMUNICATION

• FACIAL EXPRESSION
• No matter what you think about a client or what
kind of day you are having, keep your expression
neutral and friendly.
• . If the client looks upset, you should appear and be
understanding and concerned. Conversely, smiling
when the client is on the verge of tears will cause
the client to believe that you do not care about his
or her problem
NON VERBAL COMMUNICATION

• ATTITUDE
• One of the most important nonverbal skills to
develop as a health care professional is a
nonjudgmental attitude
• This involves not preaching or imposing your own
sense of ethics or morality on the client.
• Focus on healthcare and how you can best help the
client achieve the highest possible level of health
NON VERBAL COMMUNICATION
• SILENCE
• Periods of silence allows the nurse and the client to reflect
and organize thoughts, which facilitates more accurate
reporting data and collection
• LISTENING
- is the most important skill to learn and develop fully in order
to collect complete and valid data from your client. To listen
effectively, you need to maintain good eye contact, smile or
display an open, appropriate facial expression, maintain an
open body position (open arms and hands, and lean
forward).
VERBAL COMMUNICATION

• Effective verbal communication is essential to a

client interview. The goal of the interview process is
to elicit as much data about the client’s health
status as possible
 Types of Interview Questions

1. CLOSED-ENDED QUESTIONS
• Used in directive interview
• Restrictive, generally requires a “yes” or
“no” or short factual answers giving
specific information
• Often begin with “when”, “where”, “who”,
, “do (did,does)”, “is (are, was)”
 Types of Interview Questions

1. CLOSED-ENDED QUESTIONS
• How many years did you work for your last
employer?“
• "Have you ever worked in a different
industry?"
• "What's the longest you've worked for any
employer?“
• Have you ever been fired from a job? Yes or no?
 Types of Interview Questions

2. OPEN-ENDED QUESTIONS
• Used in non-directive interview
• Invite clients to discover and explore, elaborate,
clarify, illustrate their thoughts, or feelings
• Answers are longer than two words
• Gives clients freedom to divulge information
that they are ready to disclose
• Useful in the beginning of an interview or to
change topics and to elicit attitudes
• May begin with “what” or “how”
 Types of Interview Questions

2. OPEN-ENDED QUESTIONS
• Tell me about yourself.
• How would you describe yourself?
• How would your boss/co-workers and/or
subordinates describe you?
• What motivates you?
• What do you see as your strengths?
• What accomplishments are you particularly proud
of
 Types of Interview Questions
3. LAUNDRY LIST
This provide the client with a list of words to choose
from in describing symptoms, conditions, or
feelings. This laundry list approach helps you to
obtain specific answers and reduces the likelihood
of the client perceiving or providing an expected
answer

-For example, “Is the pain severe, dull,sharp,mild or

piercing? Or Does the pain occur once every year,
day, month or hour?
 Types of Interview Questions
4. REPHRASING
This technique helps you to clarify information the
client has stated; it also enables you and the client to
reflect on what was said.

5. Well-Placed Phrases
Listen closely to the client during his or her
description and use phrases such as “um-hum,”
“yes,” or “I agree” to encourage the client to continue
 Types of Interview Questions
6. Inferring
Inferring information from what the client tells you and
what you observe in the client’s behavior may elicit more
data or verify the data
7. Providing Information
Make sure that you answer every question as thoroughly
as you can. . The more clients know about their own
health, the more likely they are to become equal
participants in caring for their health.

-(Non-verbal and Verbal Communications to Avoid-

Refer to Box 2-1, page 15 of your reference book)
PHASES OF INTERVIEW
- 1. PREINTRODUCTORY PHASE
- Before actually meeting the client it is helpful
to review the client’s medical record.
- After reviewing the record or discussing the
client’s status with others, remember to keep
an open mind and to avoid premature
judgments that may alter your ability to collect
accurate data.
• Use this time to educate yourself about the
client’s diagnoses or tests performed
- Consult the necessary resources (laboratory
manual, textbook, or electronic reference resource,
such as a smart phone application) to learn about
the test and the implications of its findings.
- Once you have gathered basic data about the
client, take a minute to reflect on your own feelings
regarding your initial encounter with the client.
- Remember to obtain and organize materials that
you will need for the assessment.
1. OPENING (or Introductory)
• Most important part of the interview, sets tone for the
remainder of the interview
• Purpose is to establish rapport and orient the
interviewee
• The nurse must be careful not to overdo this stage

• In this stage, the Nurse explains the purpose & nature

of the interview, like what information is needed, how
long will it take, & what is expected of the client, how
the information will be used, & that the client has the
right not to provide data.
• The nurse also make sure that the client is comfortable
and has privacy
2. BODY (Working Phase)

• Client communicates what he or she thinks, feels,

knows, perceives in response to questions from
the nurse.
• Effective development of the interview demands
that the nurse use communication techniques that
make both parties feel comfortable & serve the
purpose of the interview
 2. BODY (Working Phase)
• During this phase, the nurse elicits the client’s
comments about major biographic 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

• The nurse then listens, observes cues, and uses

critical thinking skills to interpret and validate
information received from the client
3. Summary and Closing Phase
-During the summary and closing, the nurse
summarizes information obtained during the
working phase and validates problems and goals
with the client
-She also identifies and discusses possible plans to
resolve the problem and make sure to ask if there
is any other concerns.
-The nurse terminates the interview when the
needed information has been obtained.
-Closing is important for maintaining the rapport and
trust and for facilitating future interactions.
 STRUCTURE OF AN INTERVIEW
The following techniques are commonly used to close an
interview:
1. Offer to answer questions.
2. Conclude by saying “Well, that’s all I need to know for now.”
Preceding a remark with the word ‘well’ generally signals that the
end of the interaction ids near.
3. Thank the client. You may also shake the client’s hand.
4. Express concern for the person’s welfare and future.
5. Plan for the next meeting, if there is to be one, or state when it will
happen next.. Include the day, time, place, topic, and purpose.
6. Provide summary to verify accuracy & agreement. Summarizing
not only terminates the interview but also reassures the client that
the nurse has listened.
 PLANNING THE INTERVIEW
AND SETTING
1. Nurse should review available
information.
2. Nurse reviews the institution’s data
collection form if there’s any,
otherwise, the nurse may prepare an
interview guide.
 SPECIAL CONSIDERATIONS
DURING AN INTERVIEW
 Gerontologic Variations in Communication

 Cultural Variations in Communication

 Emotional Variations in Communication

 Gerontologic Variations in Communication
-When interviewing an older client, you must first assess
hearing acuity

-Speak clearly and use straightforward language during the

interview with the older adult client. Ask questions in simple
terms. Avoid medical jargon and modern slang.

-However, if the older client is mentally confused or forgetful,

it is important to have a significant other (e.g., spouse, child,
close friend) present during the interview to provide or clarify
the data
 Cultural Variations in Communication
-Ethnic/cultural variations in communication and self-
disclosure styles may significantly affect the information
obtained

-. If misunderstanding or difficulty in communicating is

evident, seek help from an expert, what some professionals
call a “culture broker.”

-You may have to interview a client who does not speak your
language. To perform the best interview possible, it is
necessary to use an interpreter
 Emotional Variations in Communication

-Not every client you encounter will be calm, friendly, and

eager to participate in the interview process. Clients’
emotions vary for a number of reasons.

-Clients may also have some sensitive issues with which

they are grappling and may turn to you for help
 GUIDELINES DURING AN
INTERVIEW
• Listen attentively, using all your senses,
and speak slowly and clearly.
• Clarify points that are not understood.
• Plan questions to follow a logical
sequence.
• Ask only one question at a time. Multiple
questions limit the client to one choice and
may confuse the client.
 GUIDELINES DURING AN
INTERVIEW
• Acknowledge the client’s right to look at things
the way they appear to him and not the way they
appear to the nurse or someone else.
• Do not impose your own values on the client.
• Avoid using personal examples, such as saying,
“if I were you,…”
• Nonverbally convey respect, concern, interest,
and acceptance.
 GUIDELINES DURING AN
INTERVIEW
• Be aware of the client’s and your own body
language.
• Be conscious of the client’s and your own voice
inflection, tone, and affect.
• Sit down to talk with the client (be at an even
level).
• Use & accept silence to help the client search
for more thoughts or to organize them.
• Use eye contact to be calm, unhurried, and
sympathetic.
APPLICATION:
Related Learning Experience

-Choose your partner for this activity.

-Perform a demonstration following the Phases of
Interview and integrating the guidelines in
conducting an interview.
- Use Activity C in your Lab manual as your guide for
the Working Phase of your interview.
- Conceptualize a particular case, your Reason for
Seeking Health care or Chief Complain must be
different from other groups.

40