Subjective Data Collection

• Asking open-ended questions allows patients to express their thoughts, feelings, and concerns fully.
• Sources of Data

  • Client: Best source of data, subjective data
  • Support People/Significant Other: Family members, friends, and caregivers, important source of data if the client is young, unconscious, or confused
  • Client Records: Information documented by other healthcare professionals
  • Health Care Professionals: Verbal reports
  • Literature: Journals, reference texts, published studies
• Data Collection Methods

  • Observing: To gather data using the senses, a conscious, deliberate skill. Two aspects: Noticing the data, Selecting, organizing, and interpreting the data
  • Interview: Planned communication or conversation with a purpose to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, provide counseling or therapy
• Types of Data

  • Subjective Data: Symptoms apparent only to the person affected
  • Objective Data: Signs detectable by an observer, can be measured, tested
• Phases of Interview

  1. Pre-Introductory Phase: Nurse reviews the medical record before meeting with the client. If a medical record is not established, the nurse will need to rely on interview skills to elicit valid and reliable data from the client and that individual’s family or significant other

  2. Introductory Phase: Nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential. The nurse should develop trust and rapport at this point in the interview

  3. Working Phase: Longest Phase. Verbal/Nonverbal. 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 listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client’s problems and goals

  4. Summary and Closing Phase: Summarize/Restate, Clarify. The nurse summarizes information obtained during the working phase and validates problems and goals with the client. The nurse identifies and discusses possible plans to resolve the problem (nursing diagnoses and collaborative problems) with the client. Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions
• Factors to Consider During Interview

  • Time: When the client is physically comfortable and free of pain
  • Place: Well-lighted, well-ventilated room, free of noise and distractions
  • Seating Arrangement: Ideal seating arrangement: the nurse and patient sit in two chairs placed at right angles to a desk or a table or a few feet apart with no table
  • Distance: Maintain a 2 to 3 feet distance during the interview
  • Language: Avoid medical jargon, Translators, interpreters
  • Activities of Daily Living (ADL): Hygiene, Continence, Dressing, Eating, Toileting, Transferring
• Activities of Daily Living (ADL)

  1. Hygiene

  2. Bathing, grooming, shaving, and oral care

  3. Continence

  4. Dressing

  5. Eating

  6. Toileting

  7. Transferring
• Biographical Data


  Usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others
• Reasons for Seeking Health Care

  1. Reason for seeking health care (major health problem or concern)

  2. Feelings about seeking health care (fears and past experiences)
• History of Present Illness

  1. Using COLDSPA to explore signs & symptoms

  2. Character

  3. Onset

  4. Location

  5. Duration

  6. Severity

  7. Pattern

  8. Associated Factors
• Family history is important in health assessment
• Current medications


  Inquire about medications used in the recent past and currently, prescribed or over-the-counter, purpose, dose, frequency, and any medications not prescribed for the client
• Lifestyle and health practices profile

  Understand the client's typical day, nutritional habits, weight management, activity levels, and exercise patterns
• Nutritional and weight management questions


  • 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?
• Past health history questions

  • What diseases did you have as a child?
  • What immunizations did you get and are you up to date now?
  • Do you have any chronic illnesses? If so, when were they diagnosed? How are they treated? How satisfied have you been with the treatment?
  • What illnesses or allergies did you have? How were the illnesses treated?
• Assessing pain


  Ask about other symptoms, ability to continue work or activities, how it affects daily life, possible causes, related problems, and impact on life and daily activities
• Past health history


  Inquire about childhood illnesses, immunizations, adult illnesses, past surgeries or accidents, experienced pain, allergies, hospitalizations, pregnancies, births, injuries, medications, emotional or psychiatric problems
• Activity and exercise questions

  • 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?
• Sleep and rest patterns

  Inquire about specific sleeping patterns, hours of sleep, interruptions, feeling rested, sleep problems like insomnia, and any sleep rituals used
• Activity and exercise patterns

  Assess the client's activity levels at work and home, differentiate between work activity and exercise, explain the benefits of regular exercise, and inquire about the client's exercise routine and any limitations
• Sleep and rest patterns


  Specific sleeping patterns, interruptions, feeling rested, problems sleeping (e.g., insomnia), rituals for promoting sleep, concerns regarding sleep habits
• Substance use

  Information concerning lifestyle and self-care ability, effects on health and function, sample questions about alcohol, caffeine consumption
• Sleep requirements vary depending on age, health, and stress levels
• Self-care activities


  Basic hygiene practices, regular health checkups, accident prevention, hazard protection
• Sample questions for sleep and rest patterns

  • Tell me about your sleeping patterns
  • Do you have trouble falling asleep or staying asleep?
  • How much sleep do you get each night?
• Social and community activities

  Discovering support outlets, community involvement, sample questions about fun, relaxation, socialization, and community activities
• Values and belief system

  Assessing client values, discussing philosophical, religious, and spiritual beliefs, importance in identifying problems or strengths, sample questions about life priorities
• Glasgow Coma Scale features and responses
• Levels of consciousness

  • Alert
  • Lethargy
  • Obtunded
  • Stupor
  • Coma
• Glasgow Coma Scale scores

  • Best eye response: 4, 3, 2, 1
  • Best verbal response: 5, 4, 3, 2, 1
  • Best motor response: 6, 5, 4, 3, 2, 1