Republic of the Philippines

ISABELA STATE UNIVERSITY

Echague, Isabela

College of Nursing

NUR 125 –Health Assessment

Name: Turingan, Micah Rating: _____________

Year/Section/Group: 1-1 Group 1

Introduce

purpose

NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA FROM THE CLIENT

BIOGRAPHICAL DATA
PATIENT’S PROFILE 0 1 2
Name Nida Turingan
Age 54
Gender F
Address Tramo, Malvar
Date Of Birth February 6, 1967
Birth Place Tuguegarao City
Marital Status “May partner”
Citizenship Filipino
Religion Catholic
Occupation Housewife
PRESENT HEALTH ILLNESS
Reason for seeking care/Chief “Lagi pong sumasakit ang likod ko” as she stated
Complain
Initial Management of the “Hinihilot ko nalang ng eficascent oil” as she reports
Chief Complain
Medications “kung minsan paracetamol” as verbalized by the client

History of present C- “basta masakit lang, kumikirot ganun”

illness/Health concern O- “hindi ko na matandaan, mejo matagal na”
(Use COLDSPA when Pakonti konti lang po ba ang sakit habang tumatagal?
appropriate) “pakonti konti lang”
L- “sa likod po, kung minsan sa bandang gitna, minsan
sa bandang baba”
D- “kung minsan isang araw masakit”
S- “siguro mga 5 mga ganun”
P- “nung una onti lang tas palala ng palala
A- “wala naman po”

As she completely reported

PAST HEALTH HISTORY
Childhood Illnesses “lagnat lang, sakit ng ulo ganun lang” as the client
remembers and stated
Immunization “hindi ko matandaan” as verbalise by the client
Previous Hospitalizations “ Pacheck up lang pero hindi naconfine” as she stated
Surgeries “yung ano lang, nanganak ako ng cesarian” the client
reported
Blood Transfusion “wala po”
Allergies “noong minsan kumain ako ng tahong” the client
reminisce and stated it
Accidents/Injuries “wala naman po”
Vices “wala po”
MATERNAL HISTORY
Present Obstetric History Lmp=1st day of last mens- June 1-5= June 1
(LMP, Gravidity, Parity, EDC) “Hindi ko na matandaan, matagal na e”
Menopause na po ba kayo?
“opo”

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 Client states that she already had menopause
Past Obstetric History Previous preg- “noong 2002”
(previous pregnancy, type of Type of delivery- “cesarian”
deliveries, abortion, Miscarriage- “wala naman po”
miscarriage)

FAMILY HEALTH HISTORY

Father “wala naman”

Mother “highblood lang, sakit sa puso”

Siblings “wala naman po”

Grandparents “wala naman po”

Include the 11 Gordon’s Functional Health Pattern question

Now…

Note: you are rated using criteria below:

0 – No answer
1 – Incomplete answer
2 – Complete answer

Ratings: RS x 100
N
__________________________________
Name and Signature of Clinical Instructor
Where: RS = Raw Score
N = Total Number of Items Date:
_____________________________

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 Gordon’s 11 Functional Health Questions
 Health Perception and Health Management.
History (subjective Client’s Response
data)
Client’s general health? “okay lang naman”

Any colds in past year? “oo naman, minsan lang”

If appropriate: any (housewife)

absences from
work/school?
Most important things “nageexercise” shared and even added “umiinom rin ng vitamins”
you do to keep
healthy? “hindi” as stated by the client that she is clean from vices
Use of cigarettes,
alcohol, drugs?
Perform self exams, i.e. “wala po”
Breast/testicular self-
examination?
Accidents at home, “wala po”
work, school, driving?
In past, has it been easy “opo”
to find ways to carry
out doctor’s or nurse’s
suggestions?
(If appropriate) What “hindi ko po alam, baka dahil po sa old age na” as the client verbalise
do you think caused her assumptions
current illness?
What actions have you “nilalagyan ko nalang ng efficascent oil” he client shared
taken since symptoms
started?

Have your actions “opo”

helped?
(If appropriate) What “hindi lang ako magkasakit ng grabe” hopefully said by the client
things are most
important to your
health?
How can we be most “araw-araw po”
helpful? done exercise
every what?

 Nutrition and Metabolism

History (subjective data):
Typical daily food intake including snacks? “kanin, itlog, manok, saging” the client stated

Use of supplements, vitamins? “opo, vitamins c” specified by the client

Typical daily fluid intake? “8 po”

Weight loss/gain? Height loss/gain? “nag gain ata ako ng weight kasi sumikip mga
damit ko” the client stated
“stagnant lang” as verbalise by the patient
Appetite? “Okay naman po”

Breastfeeding? Infant feeding? “hindi po”

Food or eating: Discomfort, swallowing “wala naman po”

difficulties, diet restrictions, able to
follow?
Healing – any problems? Skin problems: “wala naman po, madaling gumaling ag may sugat”
lesions? Dryness? Dental problems? “wala po”

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  Elimination
History (subjective data)
Bowel elimination pattern (describe) “minsan dalawang beses”
Frequency, character, discomfort, “mejo basa lang”
problem with bowel control, use of “parang lightbrown o cream, yellowish mga ganun” the
laxatives (i.e. type, frequency), etc.? client shared
“wala naman po” the client assured there’s no problem
in bowel elimintion
Urinary elimination pattern (describe) “madalas po, mga lima siguro” as verbalise by the
Frequency, problem with bladder patient
control? “wala naman po”
Excess perspiration? Odour “wala naman po, pag nag exercise lang ako” the client
problems? Body cavity drainage, said
suction, etc.? “wala po”

 Activity and Exercise.

History (subjective data)
Sufficient energy for desired and/or “opo”
required activities?

Exercise pattern? Type? regularity? “yung madali lang”

“simple lang, stretching mga ganun”
“Sa umaga”
As the client shared
Spare time (leisure) activities? “nanonood lang ng TV”

Child-play activities? “hindi po”

Perceived ability for feeding, grooming, “opo”

bathing, general mobility, toileting, home
maintenance, bed mobility, dressing and
shopping?

 Cognition and Perception

History (subjective data)
Hearing difficulty? Hearing aid? “wala naman po”

Vision? Wears glasses? Last “meron po” as verbalise by the patient

checked? When last changed? “nung 2015 o 2014” as the client shared

Any change in memory? “opo”

Concentration?
Important decisions easy/difficult “depende, kadalasan mahirap kung ako lang
to make? magdedesisyon”
Easiest way for you to learn things? “minsan” the client said
Any difficulty? “halimbawa sa paggamit ng computer ganun” as she
Any discomfort? Pain? shares her difficulty in learning
Character (how does it feel, look, “wala naman po”
smell, sound?)
Onset (When did it begin: is it
better, worse, or same since it
began?)
Location/radiation (Where is it?
Does it radiate?)
Duration (How long it lasts? Does it
recur?)
Severity (use rating scale)
Pattern (What makes it better,
worse?)
Associated factors (What other

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 symptoms do you have with it? Will
you be able to continue doing your
work or other activities ?)

 Sleep and Rest.

History (subjective data)
Generally rested and ready for “opo”
activity after sleep?

Sleep onset problems? Aids? “minsan po, di po agad makuha ang pagtulog”
Dreams (nightmares), early
awakening?

Rest / relaxation periods? “after lunch”

 Self-Perception and Self-Concept.

History (subjective data)
How do you describe yourself? “maganda syempre” she confidently said

Most of the time, feel good (or not so “minsan lang” the client said
good) about self?

Changes in body or things you can do? “feeling ko tumaba ako”

Problems for you? Yun po ba prinoproblema niyo?
“hindi naman”
Changes in the way you feel about self or “”kung minsan di ko na nagagawa yung ginagawa ko
body (generally or since illness started)? dahil sa sakit” the client stated

Malungkot po ba dahil ganun?

“Opo”
Things frequently make you angry? “pasaway na anak saka yung mga alaga sa bahay,
Annoyed? Fearful? Anxious? Depressed? maingay”
Not able to control things? What helps? “minsan” she shared the difficulty to control

“wala naman, tinitiis ko nalang” as verbalise by the

client
Ever feel you lose hope? “hindi naman”

 Roles and Relationships.

History (subjective data)
Live alone? “hindi po, may kasama po ako”

Family? Family structure? Any family problems “anak at asawa lang po” the client stated
you have difficulty handling (nuclear/extended “wala po” she reported
family)? Family or others depend on you for
things? How well are you managing?

If appropriate – How families/others feel about “wala naman po”

your illness?

Problems with children? “meron, kung minsan pasaway” the client

shared
Belong to social groups? “wala po”

Close friends? Feel lonely? (Frequency) “wala po” the client said
“hindi naman” she also shared that being
alone doesn’t make her lonely
Things generally go well at work / school? (housewife only)

If appropriate – income sufficient for needs? (housewife only)

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 Feel part of (or isolated in) your neighborhood? “hindi naman”

 Sexuality and Reproduction.

History (subjective data)
If appropriate to age and situation – “wala” the client stated
Sexual relationships satisfying? Changes? “wala po” as verbalise that there’s no changes
Problems? “wala naman” the client also added that there are
no problems
If appropriate – Use of contraceptives? “hindi po”
Problems?

Female – when did menstruation begin? “noong elementary, 12 yrs old”

Last menstrual period (LMP)? Any “hindi ko na matandaan”
menstrual problems? Menopause na po ba?
“opo”
(Gravida//Para if appropriate) “isang beses lang”

 Coping and Stress Tolerance.

History (subjective data)
Any big changes in your life in last year “nakakaranas naman, kasi nawalan nga ng trabaho
or two? Crisis? yung kasama ko” the client shared

Who is most helpful in talking things “yung kasama ko, yung partner ko”
over? Available to you now?

Tense or relaxed most of the time? “kung minsan stress, di maiwasan yun”
When tense, what helps? Kung mararatio niyo po ang stress at relax, ano pong
ratio? 50:50, 60:40?
“50:50” the client reported
Use any medications, drugs, alcohol to “hindi po” she said
relax?

When (if) there are big problems in “kinakausap ko nalang yung kasama ko” the client
your life, how do you handle them? shared
Most of the time, are these ways “opo”
successful?

 Values and Belief.

History (subjective data)
Generally get things you want from “magkaroon ng magandang buhay” the client stated what
life? she wants to get and also shared if she gets it by stating
“minsan lang”
Important plans for future? “wala naman, basta makatapos lang anak ko”

Religion important to you? If “opo” She shared

appropriate - Does this help when “opo” the client also agreed that religion helps
difficulties arise?

If appropriate – will being here “wala naman po”

interfere with any religious
practices?
Health beliefs/values? “wala naman”

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