SESSION 3

• Nursing process data collection

  Two focuses: Establishing rapport and a trusting relationship, Gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual statuses
• Three basic phases of client interview

  • Introductory Phase + Pre-Introductory Phase
  • Working Phase
  • Summary and Closing Phase
• Pre-Introductory Phase


  1. Review of the medical records before meeting the client

  2. Information may assist the nurse by knowing some of the client's documented biographical information

  3. Client's additional information may be revealed if previous data is already present in the system

  4. Client records may also reveal reasons for seeking health care and past health history

  5. Nurses need to rely on interview skills from the client and significant others in the absence of an established medical record
• Introductory Phase


  1. Explain the purpose of the interview

  2. Discuss the types of questions that will be asked

  3. Explain the reason for taking notes

  4. Assure confidentiality to the client

  5. Ensure the client is comfortable (physically and emotionally) and with privacy
• Subjective data


  Key step of nursing health assessment which is gathered by means of client interview, Integral part of client interview to obtain nursing health history, Consist of information elicited and verified only by the client, Provides the nurse with information that may reveal a client's risk for problems as well as areas of strengths for the client, Complete health history is done to collect as much subjective data about the client
• Objective data


  Essential for a complete nursing assessment, Collection requires a great deal of practice to become proficient, Includes information about the client which the nurse directly observes during the interaction with the client, Information is elicited through physical assessment (examination) techniques
• Verbal communication to develop rapport


  • Open-ended questions
  • Closed-ended questions
  • Laundry list
  • Rephrasing
  • Well-placed phrases
  • Inferring
  • Providing information
• Nonverbal communication to develop rapport

  • Appearance
  • Demeanor
  • Facial expression
  • Attitude
  • Silence
  • Listening
• Verbal communication to avoid


  • Biased or leading questions
  • Rushing through the interview
  • Reading the questions
• Nonverbal communication to avoid

  • Excessive or insufficient eye contact
  • Distraction and distance
  • Standing
• Working Phase


  1. Elicit the clients comments about: Major biographic data, Reasons for seeking health care, History of present concern, Past health history, Family history, Review of body systems (for current health problems), Life style and health practices, Developmental level

  2. Nurse listens, observes cues, and uses critical thinking skills to interpret and validate the information

  3. Nurse and client collaborate to identify client's problems and goals
• Variations in communication


  • Gerontologic
  • Cultural
  • Emotional
• Lifestyle and health practices


  • Description of typical day
  • Nutrition and weight management
  • Activity level and exercise
  • Sleep and rest
  • Substance use
  • Social activities
  • Relationships
  • Values and belief system
  • Education and work
  • Stress levels and coping styles
  • Environment
• Description of typical day

  1. Elicit an overview of how the client sees his usual pattern of daily activity

  2. Questions asked should be vague enough to allow the client to provide of orientation from which the day is viewed

  3. Start with awakening in the morning and continue until bedtime

  4. Additional specific questions may be asked to draw out more details if the client gives minimal information

  5. Encourage the client to discuss a usual day
• Nutrition and weight management

  1. Ask the client to recall what consists of an average 24-hour intake with emphasis on what foods are eaten and in what amounts

  2. Identify who buys and prepares the food as well as when where meals are eaten

  3. Clients' food intake should be compared with the guidelines illustrated in the food pyramid

  4. Check for the patient's bowel and bladder habits
• Activity level and exercise

  1. Inquiry for regular exercise

  2. Distinguish between activity is done when working (stressful and fatiguing) and exercise (designed to reduce stress and strengthen individual)

  3. Explain regular exercise reduces the risk of heart disease, and stress, strengthens the heart and lungs, and manages weight

  4. Distinguish the client's answers with a recommended exercise regimen (20 to 30 minutes / three times a week)
• Sleep and rest


  1. Questions should focus on specific sleep patterns such as how the many hours a night the person sleeps

  2. Compare the client's answers with the normal sleep requirement for adults (5 to 8 hours a night)

  3. Identify interruptions, problems with sleeping, rituals, and concerns about sleeping habits

  4. Sleep requirements vary depending on age, health, and stress levels
• Stanford Sleepiness Scale


  Degree of sleepiness scale rating from 1 (Feeling active, vital, alert, or wide awake) to 7 (No longer fighting sleep, sleep onset soon, having dream-like thoughts), Foggy = lack of focus and or decrease in mental clarity, Score rating of 1= Ideal, Score greater than 3 = Serious sleep debt and requires more sleep, 9AM to 9PM = Daily peak times for alertness, 3PM = Usually lowest point of alertness
• Substance use


  1. Information gathered about substance use provides the nurse with information concerning lifestyle and the client's self-care ability

  2. Identify how often the client takes the substance and inquire for the amounts consumed

  3. Substances are known to affect the client's health and may cause loss of function or impaired senses

  4. Substances increase the client's risk for diseases
• Social activities


  Helps the nurse to identify outlets the client has for support and relaxation (involvement in the community beyond family and work information to determine the client's current level of social development)
• Relationships


  1. Ask for the composition of the family into which they were born and about past and current relationships with these family members

  2. Assess problems and potential support from the client's family of origin

  3. Similar information may be sought about the client's current family

  4. In absence of family by blood or marriage, gather information from significant others that may constitute the client's "family"
• Values and belief system

  1. Discuss the client's philosophical, religious, and spiritual beliefs

  2. Some clients may not be comfortable with discussing values or beliefs

  3. Data gathered may help to identify important problems or strengths
• Education and work


  1. Identifies areas of stress and satisfaction in the client's life

  2. Discussing this area will help the client feel good about what he has accomplished and promote his sense of life satisfaction

  3. Questions should bring out data about the kind and amount of education the client has

  4. Similar questions should be asked about work history
• Stress levels and coping styles

  1. Questions that address what events cause stress for the client

  2. Identification of how the client responds to stress

  3. To avoid denial responses, nondirective questions or observations regarding previous information provided by the client may be an easy way to establish discussion

  4. Allow the healthcare provider to find out what relieves stress and whether the behaviors/activities can be construed as adaptive or maladaptive
• Environment


  1. For the assessment of health hazards unique to the client's living situation and lifestyle

  2. Look for physical, chemical, and psychological situations that may put the client at risk

  3. Hazards may be controllable and uncontrollable and may be found in the client's home, work, neighborhood and or recreational environment
• Client positioning for objective data collection (physical assessment)

  • Sitting position
  • Supine position
  • Dorsal recumbent position
  • Sims position
  • Standing position
  • Prone position
  • Knee-chest position
  • Lithotomy position
• Sitting position


  1. Good for head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities

  2. Permits full expansion of the lungs

  3. Assessment for symmetry of upper body parts

  4. Supine position with the head elevated as an alternative position
• Supine position


  1. Small pillows may be placed under the head to promote client comfort

  2. Position allows the abdominal muscles to relax

  3. Provides easy access to peripheral pulse sites

  4. Head of the bed may need to be raised for the difficulty of breathing
• Dorsal recumbent position


  1. Client lies down with knees bent and legs separated and the feet flat on the bed

  2. Abdomen should not be assessed due to contraction in the position

  3. May be more comfortable than the supine position for clients with pain in the back or abdomen
• Sims position


  1. Client lies on the right or left side with the lower arm placed behind the body and the upper arm flexed at the shoulder and elbow

  2. Lower leg slightly flexed at the knee while the upper leg is flexed at a sharper angle and pulled forward

  3. Used for assessing rectal and vaginal areas

  4. Client may need some assistance in the position

  5. Elderly and clients with joint problems may have difficulty in assuming and maintaining the position
• Standing position


  1. Client stands still in a normal, comfortable, and resting posture

  2. Allows examiner to asses posture and gait

  3. Used for examining the male genitalia
• Prone position


  1. Client lies down on the abdomen with the head to the side

  2. Used primarily to assess hip joint and back of the client

  3. Clients with respiratory problems cannot tolerate the position
• Knee-chest position


  1. Client kneels on the examination table with the weight of the supported by the chest and knees

  2. 90-degree angle should exist between the body and hips (head turned to side, arms placed above the head)

  3. Useful in examining the rectum

  4. Maybe embarrassing and uncomfortable for the client

  5. Client should be kept in the position for as limited time as possible

  6. Elderly and clients with respiratory and cardiac problems may be unable to tolerate the position
• Lithotomy position


  1. Client lies on the back with the hips at the edge of the examination table (feet supported by stirrups)

  2. Used for examination of the female genitalia, reproductive tracts, and rectum

  3. As an exposed position, the client may feel embarrassed, and is best to keep the client well-draped during the examination

  4. Perform examination as quickly as possible
• Physical assessment


  Information about the client that the nurse directly observes during interaction with the client, Information elicited through physical assessment (examination) techniques
• Proficiency in physical assessment skills requires

  • Types and operation of equipment needed for the particular examination
  • Preparation of the setting, oneself, and the client for the physical assessment
  • Performance of the four assessment techniques
• Preparing equipment


  Prior to the client assessment, to promote a sense of organization and to prevent the nurse from leaving the client to search for equipment, the examiner must collect the necessary equipment and place it in the examination area
• Preparing physical setting


  Nurse must ensure that the examination setting meets the following conditions: Comfortable, warm room temperature, Private area free of interruptions from others, Quiet area free of distractions
• Preparing oneself


  For beginning examiners, it is best to assess your own feelings and anxieties before examining the client, Achieve self-confidence in performing a physical assessment by practicing related techniques, Ensure the prevention of transmission of infectious agents
• Preparing client


  Establish the nurse-client relationship during the interview before the physical assessment, Respect the client's desires and requests related to physical examination, Begin the examination with less intrusive procedures such as measuring the vital signs, height, and weight, Approach the client from the right-hand side of the examination table or bed since most examination techniques are performed with the examiner's right hand