WEEK 3 - STEPS OF HEALTH ASSESSMENT

Spectacular Day! The subjective examination is often undervalued in the assessment and
management of a patient. It is the most crucial aspect of the examination as it determines the
severity, irritability and nature of the patient’s condition. Good questioning leads to the formation
of primary and secondary hypotheses, possible methods of treatment and likely prognosis of the
injury. The purpose of obtaining a subjective data from the patient and/or the patient’s family so
that the health care team and the patient can collaboratively create a plan that will promote health,
address acute health problems, and minimize chronic health conditions.
Steps of Health Assessment
1. Collection of Subjective Data
Subjective data are 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. To elicit accurate subjective data, learn to use effective interviewing
skills with a variety of clients in different settings. The major areas of subjective data include:  
      Biological information (name, age, religion, occupation)
      History of present health concern: physical symptoms related to each body parts or system
(e.g., eyes and ears, abdomen)
     Personal health history
     Family history
     Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition,
activity, relationships, cultural beliefs or practices, family structure and function, community
environment)
 Review of the system
 

How can you gather subjective data? 

These types of data can be elicited and verified only by the client.
Subjective data provide clues to possible physiologic, psychologic and sociologic
problems. They also provide the health provider with information that may reveal
a client’s risk for a problem as well as areas of strengths for the client.
 

A. Focus of Interview
Interview is a planned communication or a conversation with a purpose, for example, to get or
give information, identify problems of mutual concerns, evaluates change, teach, provide support or
provide counseling or therapy.
 
Obtaining a valid health history requires interpersonal, and interviewing skills, interview is a
communication process that has two focuses:
       Establishing rapport and a trusting relationship with the client to elicit accurate and
meaningful information
    Gathering information on the client's developmental, psychological, physiologic,
sociocultural, and spiritual status to identify deviations that can be treated and collaborative
interventions   or strengths that can be enhanced through provider-client collaboration.
 
How will you approach during interview?
1.       Directive Interview– highly structured and elicits specific information.
     The health provider establishes the purpose of the interview and controls the interview,
at least at the outset.
     Emergency situation
1.      Indirective Interview– rapport-building interview.
     The health provider allows the client to control the purpose, subject matter, and pacing.
RAPPORT = an understanding between 2 or more people.
 

B. Phases of Interview
1. Preintroductory Phase
The health provider reviews the record before meeting with the client. Knowing some of the
client's already documented biographical information may assist the health provider with conducting
 the interview. If the client has been in the system for some time, the record may reveal additional
information. For example, it may indicate that the client has difficulty hearing in one ear. This
information will ensure that the health provider conducts the interview on the side on which the client
hears best. The record may also reveal the client's past health history and reason for seeking health
care. However, there may not be a medical record established in some instances. Health provider will
then need to rely on interviewing skills to elicit valid and reliable data from the client and the client's
family or significant other.
 
1. Introductory Phase
After introducing herself to the client, the health provider 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. Conducting the interview at
eye level with the client demonstrates respect and places the health provider and the client at equal
levels. At this point in the interview, it is also essential for health providers to develop trust and
rapport, which are essential to promote full disclosure of information. The health provider can begin
this process by conveying a sense of priority and interest in the client. Developing rapport depends
heavily on verbal and nonverbal communication on the part of the health provider. These types of
communication are discussed later in the chapter.
 
1. Working Phase
During this phase, the health provider elicits the client’s comments about major biographical data,
reasons for seeking care, history of present health concern, past health history, family history, review
of body systems (ROS) for current health problems, lifestyle and health practices, and developmental
level. The health provider then listens, observes cues, and uses critical thinking skills to interpret and
validate information received from the client. The health provider and client collaborate to identify
the client's problems and goals. The facilitating approach may be free flowing or more structured with
specific questions, depending on the time available and the type of data needed.
 
1. Summary and Closing Phase
During the summary and closing, the health provider 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 (collaborative problems) with the. Finally, the health provider
makes sure to ask if anything else concerns the client and if there are any further questions.
 

How to communicate during the Interview?

The client interview involves two types of communication— nonverbal and verbal. Several
special techniques and certain general considerations will improve both types of communication as
well as promote an effective and productive interview.
1. Nonverbal Communication
Nonverbal communication is as important as verbal communication. Your appearance,
demeanor, posture, facial expressions, and attitude strongly influence how the client perceives the
questions you ask. Facilitate eye level contact. Never overlook the importance of communication or
take it for granted.

a. 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
 laboratory coat or a uniform. Be sure that your nametag, including credentials, is clearly visible. Your
hair should be neat and pulled back if long. Fingernails should be short and neat; jewelry should be
minimal.
b. Demeanor
Your demeanor should also be professional. When you enter a room to interview a client,
display poise. Focus on the client and the upcoming interview and assessment. Do not enter the room
laughing loudly, yelling to a coworker, or muttering under your breath. This appears unprofessional to
the client and will have an effect on the entire interview process. Greet the client calmly, by name and
not with references such as honey, sweetie, or sugar. Focus your full attention on the client. Do not be
overwhelmingly friendly or "touchy"; many clients are uncomfortable with this type of behavior. It is
best to maintain a professional distance.
c. Facial Expression
Facial expressions are often an overlooked aspect of communication. Because facial
expressions often show what you are truly thinking (regardless of what you are saying), monitor them
closely. No matter what you think about a client or what kind of day you are having, keep your
expression neutral and friendly. If your face shows anger or anxiety, the client will sense it and may
think it is directed toward him or her. If you cannot effectively hide your emotions, you may want to
explain briefly that you are angry or upset about a personal situation. Admitting this to the client may
also help in developing a trusting relationship and genuine rapport.
Displaying a neutral expression does not mean that your face lacks expression. It means using
the right expression at the right time 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.
d. Attitude
One of the most important nonverbal skills to develop as a health care professional is a
nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle and
health care practices Do not act as though you feel superior to the client or appear shocked, disgusted,
or surprised at what you are told. These attitudes will cause the client to feel uncomfortable about
opening up to you, and important data concerning his or her health status could be withheld.
Being nonjudgmental involves not “preaching" or imposing your own sense of ethics or
morality on the client. Focus on health care and how you can best help the client to achieve the
highest possible level of health. For example, if you are interviewing a client who smokes, avoid
lecturing condescendingly about the dangers of smoking. Also, avoid telling the client that he or she is
foolish and avoid projecting an attitude of disgust. This will only harm the provider—client
relationship and bill do nothing to improve the client's health. Tie client is, no doubt, already aware of
the dangers of smoking. Forcing guilt on the client is unhelpful. Accept the client, be understanding of
the habit, and work together to improve the client's health. Ibis does not mean you should not
encourage the client to quit it means that how you approach the situation makes a difference Let the
client know you understand that it is hard to quit smoking support efforts to quit, and offer
suggestions on the latest methods available to help kick the smoking habit, such as the Five A's of
Behavior Change: Ask, Advise, Assess, Assist, Arrange.
e. Silence
Another nonverbal technique to use during the interview process is silence. Periods of silence
allow you and the client to reflect and organize thoughts, which facilitate more accurate reporting and
data collection.
f. Listening
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, and maintain an open body position (open arms and
hands, and lean forward). Avoid preconceived ideas or biases about your client. To listen effectively,
you must keep an open mind. Avoid crossing your arms, sitting back, tilting your head away from the
client, thinking about other things, looking blank or inattentive, or engaging with an electronic device
instead of the client. Becoming an effective listener takes concentration and practice.
1. 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. Several types of questions
and techniques to use during the interview are discussed in the following sections.
a. Open-Ended Questions
Open-ended questions are used to elicit the client's feelings and perceptions. They typically
begin with the words "how" or "what." An example of this type of question is: "How have you been
feeling lately?" These types of questions are important because they require more than a one-word
response from the client and, therefore, encourage description. Asking open-ended questions may
help to reveal significant data about the client's health status.
The following example shows how open-ended questions work. Imagine yourself interviewing
an elderly male client who is at the primary care provider's office because of diabetic complications.
He mentions casually to you, "Today is the 2-month anniversary of my wife's death from cancer.
Failure to follow up with an open-ended question such as "How does this make you feel?" may result
in the loss of important data that could provide clues to the client's current state of health.
b. Closed-Ended Questions
Use closed-ended questions to obtain facts and to focus on specific information. The client can
respond with one or two words. Closed-ended questions typically begin with the words "when" or
"did." An example of this type of question is: "When did your headache start?" Closed-ended
questions are useful in keeping the interview on course. They can also be used to clarify or obtain
more accurate information about issues disclosed in response to open-ended questions. For example,
in response to the open-ended question "How have you been feeling lately?" the client says, "Well, I've
been feeling really sick to my stomach and I don't feel like eating because of it." You may be able to
follow up and learn more about the client's symptom with a closed-ended question such as "When did
the nausea start?"
c. Laundry List
Another way to ask questions is to 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, cutting, or piercing?" "Does the pain occur once every
year, day, month, or hour?" Repeat choices as necessary.
d. Rephrasing
Rephrasing information the client has provided is an effective way to communicate during the
interview. This technique helps you to clarify information the client has stated; it also enables you and
the client to reflect on what was said. For example; your client, Mr. G., tells you that he has been really
tired and nauseated for 2 months and that he is scared because he fears that he has some horrible
disease. You might rephrase the information by saying, "You are thinking that you have a serious
illness?"
e. Well-Placed Phrases
The health provider can encourage client verbalization by using well placed phrases. For
example, if the client is in the middle of explaining a symptom or feeling and believes that you are not
paying attention, you may fail to get all the necessary information. Listen closely to the client during
his or her description and use phrases such as "uh-huh," "yes," or "I agree" to encourage the client to
continue.
f. Inferring
Inferring information from what the client tells you and what you observe in the client's
behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that
are not true (see the Verbal Communication to Avoid section in Box 2-1 for more information). An
example of inferring information follows: your client, Mrs. J., tells you that she has bad pain. You ask
where the pain is, and she says, "My stomach." You notice the client has a hand on the right side of
her lower abdomen and seems to favor her entire right side. You say, "It seems you have more
difficulty with the right side of your stomach" (use the word "stomach" because that is the term the
client used to describe the abdomen). This technique if used properly, helps to elicit the most accurate
data possible from the client.
g. Providing Information
Another important thing to do throughout the interview is to provide the client with
information as questions and concerns arise. Make sure that you answer every question as thoroughly
as you can. If you do not know the answer, explain that you will find out. The more clients know about
their own health, the more likely they are to become equal participants in caring for their health. As
with nonverbal communication, several verbal techniques may hinder effective communication and
should be avoided.
 

C. Communication to Avoid

Nonverbal Communication To Avoid Verbal Communication To Avoid

 a. Biased or Leading Questions
Avoid using biased or leading
questions. These cause the client to
provide answers that may not be true.
The way you phrase a question may
actually lead the client to think you
a. Excessive or Insufficient Eye Contact want her to answer in a certain way.
For example, if you ask "You don't feel
Avoid extremes in eye contact. Some clients feel very
bad, do you?" the client may conclude
uncomfortable with too much eye contact; others
that you do not think she should feel
believe that you are hiding something from them if you
bad and will answer "no" even if this is
do not look them in the eye. Therefore, it is best to use
not true.
a moderate amount of eye contact. For example,
establish eye contact when the client speaking to you b. Rushing Through the Interview
but look down at your notes from time to time. A Avoid rushing the client. If you ask
client's cultural background often determines how he questions on top of questions, several
feel about eye contact. things may occur. First, the client may
b. Distraction and Distance answer a series of closed-ended
questions when he or she would have
Avoid being occupied with something else while you
answered "yes" to one of the questions
are asking questions during the interview. This
if it was asked individually. This may
behavior makes the client believe that the interview
occur because the client did not hear
may be unimportant to you. Avoid appearing mentally
the individual question clearly or
distant as well. The client will sense your distance and
because the answers to most were "no"
will be less likely to answer your questions thoroughly.
and the client forgot about the "yes"
Also try to avoid physical distance exceeding 2—3 ft
answer in the midst of the others. With
during the interview. Rapport and trust are established
this type of interview technique, the
when clients sense that your focus and concern are
client may believe that his individual
solely on them and their health. Physical distance may
situation is of little concern to the
portray a non-caring attitude or a desire to avoid close
health provider. Taking time with
c. Standing clients shows that you are concerned
Avoid standing while the client is seated during the about their health and helps them to
interview. Standing puts you and the client at different open up. Finally, rushing someone
levels. You may be perceived as the superior, making through the interview process
the client feel inferior. Care of the client's health shouldundoubtedly causes important
be an equal partnership between the health care information to be left out of the health
provider and the client. If the client is made to feel history. A client will usually sense that
inferior, he or she will not feel empowered to be an you are rushed and may try to help
equal partner and the potential for optimal health may hurry the interview by providing
be vital information may not be revealed if the client abbreviated or incomplete answers to
believes that the interviewer is untrustworthy, questions.
judgmental, or disinterested. c. Reading the Questions
Avoid reading questions from the
history form. This deflects attention
from the client and results in an
impersonal interview process. As a
result, the client may feel ill at ease
opening up go formatted questioning.

GENERALIZATION
Collecting subjective data is a key step of health assessment. Subjective data consist of
information elicited and verified only by the client. Interviewing is the means by which subjective data
are gathered. Two types of communication are useful for interviewing: nonverbal and verbal.
Variations in communication, such as gerontologic, cultural, and emotional variations, may be
encountered during the client interview. Nonverbal communication comprises: appearance;
demeanor; facial expression; attitude; silence; listening. While verbal communication
comprises: open-ended questions; closed-ended Questions; laundry list; rephrasing; well-placed
phrases; inferring; and providing information.
The patient's story is considered to be the key to the medical interview, and asking the right
questions and actively listening to the patient can best obtain this story. As you interview the patient,
you will come to realize that an organized approach provides a solid foundation, but you must follow
the patient's story in the order it is being told versus the patient answering your questions in a
predetermined order. This being said, it is necessary to know the core elements of the systematic
approach to a patient interview to ensure that all the components are addressed and eventually
documented and/or communicate in an organized manner that is recognized by all healthcare
professionals.
  

"Nobody cares how much you know until

they know how much you care”.
Theodore Roosevelt