Guided Lecture Notes, Chapter 2, Collecting Subjective Data: The Interview and
Health History
Interviewing
Learning Objective 1. Discuss the purpose for each of the three phases of a client
interview.
Review the following three phases of the interview process and what occurs in each
phase (refer to PowerPoint slides 2 to 8):
o Introductory
o Working
o Summary and closing
Learning Objective 2. Describe effective verbal and nonverbal communication
techniques to collect subjective client data.
Discuss the importance of verbal communication during a client interview.
Review the following aspects of verbal communication that occur during the
interview (refer to PowerPoint slides 11 to 13):
o Open-ended questions
o Closed-ended questions
o Laundry list
o Rephrasing
o Well-placed phrases
o Inferring
o Providing information
Review the following aspects of nonverbal communication that occur during the
interview (refer to PowerPoint slide 9):
o Appearance
o Demeanor
o Facial expression
o Attitude
o Silence
o Listening
Learning Objective 3. Explain types of communication to avoid in the client interview.
Discuss the following verbal communication to avoid during a client interview (refer
to PowerPoint slide 14):
o Biased or leading questions
o Rushing through the interview
o Reading the questions
Discuss the following nonverbal communication to avoid during a client interview
(refer to PowerPoint slide 10):
o Excessive or insufficient eye contact
o Distraction and distance
o Standing
Learning Objective 4. Describe ways to adapt the interview for the older client.
Explain why care should be taken when interviewing elderly clients (refer to
PowerPoint slide 15).
Discuss the gerontologic variations in communication.
Learning Objective 5. Describe ways to adapt the interview for the client with emotional
issues.
Discuss the appropriate ways to communicate with clients with the following
emotional states (refer to PowerPoint slides 15 to 21):
o Anxious client
o Angry client
o Depressed client
o Manipulative client
o Seductive client
o Discussing sensitive issues
Learning Objective 6. Describe the ways that ethnicity can affect communication
patterns.
Discuss the variations in ethnicity and explain how they may influence client
interviews (refer to PowerPoint slide 15).
Discuss the alternate methods or aids to communication when interviewing clients
who speak a different language.
Learning Objective 7. Identify the major categories of a complete client health history.
Emphasize the fact that a complete health history includes the following components
(refer to PowerPoint slides 22 to 26):
o Biographical data
o Reasons for seeking health care
o History of present health concern
o Past health history
o Family health history
o Review of systems for current health problems
o Lifestyle and health practices profile
o Developmental level
Learning Objective 8. Describe how to use a genogram to illustrate a client’s family
health history.
Explain the use of a genogram (refer to PowerPoint slides 25 and 26).
Learning Objective 9. Describe the process for performing a review of systems.
Discuss the following body systems reviewed for current health problems (refer to
PowerPoint slides 27 and 28):
o Skin, hair, nails
o Head, neck
o Eyes
o Ears
o Mouth, throat, nose, sinuses
o Thorax, lungs
o Breasts, regional lymphatics
o Heart, neck vessels
o Peripheral vascular
o Abdomen
o Genitalia
o Anus, rectum, prostate
o Musculoskeletal
o Neurologic
Learning Objective 10. Describe questions to ask to assess the client’s lifestyle and
health practices.
Discuss the areas assessed regarding lifestyle and health practices.
Explain how the following information regarding lifestyle and health practices is
useful when obtaining a health history of the client (refer to PowerPoint slides 29
and 30):
o Description of typical day
o Nutrition and weight management
o Activity level and exercise
o Sleep and rest
o Medication and substance use
o Self-concept and self-care responsibilities
o Social activities
o Relationships
o Values and belief system
o Past, present and future education and work
o Type of work, level of job satisfaction, work stressors
o Stress levels and coping strategies
o Residency, environment, neighborhood, environmental risks
Learning Objective 11. Explain how a nurse would use the “COLDSPA” mnemonic to
analyze a client symptom.
Mnemonic Question
Character Describe the sign or symptom (feeling, appearance, sound,
smell, or taste if applicable).
Onset When did it begin?
Location Where is it? Does it radiate? Does it occur anywhere else?
Duration How long does it last? Does it recur?
Severity How bad is it? or How much does it bother you?
Pattern What makes it better or worse?
Associated factors/ What other symptoms occur with it? How does it affect you?
How it Affects the
client
